Hiroyuki Tanaka
This case illustrates that in severe TBM, where both airway patency and gas exchange are compromised, ECMO may serve as a strategic bridge to definitive airway intervention. This case illustrates features of both an anatomically difficult airway (critical central airway collapse) and a physiologically difficult airway (severe hypoxemic respiratory failure), highlighting the importance of managing both airway anatomy and physiology simultaneously. Early extracorporeal support may be considered in carefully selected patients with reversible causes of severe respiratory failure.
BACKGROUND: Tracheobronchomalacia (TBM) is characterized by the excessive expiratory collapse of the central airway due to structural weakness or membranous redundancy of the tracheal and bronchial cartilages. TBM may present with anatomical and physiological compromise of the airways. Aggressive treatments for severe respiratory failure include mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Interventional approaches include short-term silicone stent trials to predict surgical benefits and definitive procedures, such as tracheobronchoplasty.
CASE PRESENTATION: An Asian male patient in his 60s with a history of COPD receiving home oxygen therapy (HOT) was transferred to our hospital for dyspnea. His baseline symptoms were classified as Hugh-Jones Class III. Upon admission, the partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2) ratio was 110. Computed tomography (CT) revealed bilateral narrowing of the trachea and bronchi. Estimated expiratory airway collapse for repeated CT scans was 75%, and limited dynamic 3D airway reconstruction demonstrated expiratory tracheal collapse, supporting the diagnosis of TBM. The patient received high-flow nasal oxygen therapy but gradually deteriorated and required mechanical ventilation. Biopsy revealed expanded submucosal fibrosis. The patient's respiratory status deteriorated on the 11th day after admission with no improvement in any ventilator settings. Venous-venous ECMO was performed. Airway stenting was performed on the 20th day of admission. ECMO was discontinued on the 28th day, and the patient was weaned from the ventilator on the following day (Day 29).
CONCLUSIONS: This case illustrates that in severe TBM, where both airway patency and gas exchange are compromised, ECMO may serve as a strategic bridge to definitive airway intervention. This case illustrates features of both an anatomically difficult airway (critical central airway collapse) and a physiologically difficult airway (severe hypoxemic respiratory failure), highlighting the importance of managing both airway anatomy and physiology simultaneously. Early extracorporeal support may be considered in carefully selected patients with reversible causes of severe respiratory failure.