The assessment of major airway function in a ventilator-dependent patient with tracheomalacia

A 60-pack-year smoker presented with cough, dyspnea and orthopnea of three months' duration. Spirometry revealed severe reduction in maximal expiratory flow; CT of the chest and bronchoscopy demonstrated expiratory collapse of a mid-tracheal segment, and a presumptive diagnosis of tracheomalacia was made. A right lateral thoracotomy was performed to resect the unstable segment and improve maximal expiratory flow. Diffuse major airway disease with absence of cartilaginous rings from the thoracic inlet to the mainstem bronchi was encountered. The trachea and mainstem bronchi were stented externally. A high resistance to airflow and absence of expiratory flow limitation were present, suggesting a fixed rather than variable intrathoracic obstruction of major airways. This case illustrates some potential pitfalls in preoperative assessment of patients with tracheomalacia. Recordings of airway pressure and flow during mechanical ventilation are useful in distinguishing between fixed and variable intrathoracic obstruction and may complement tests of airway anatomy.