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Mayo Clinic College of Medicine, Rochester, MN
Correspondence to: John Park, MD, FCCP, Mayo Clinic College of Medicine, Pulmonary/Critical Care/Sleep, 200 First Ave SW, Rochester, MN 55905; e-mail: park.john{at}mayo.edu
To the Editor:
We applaud Carden and colleagues for their excellent review of tracheomalacia (March 2005).1 We would, however, like to clarify the definition.
Tracheomalacia, according to Taber’s Cyclopedic Medical Dictionary is, "softening of the cartilages of the trachea."2 This is distinct from dynamic airway collapse (DAC), which is due to excessive laxity of the posterior membranous wall with an intact integrity of the cartilaginous support.3 This results in tracheal collapse during expiration but preserves airway caliber during inspiration. Although the review by Carden et al1 suggested the abnormality in tracheomalacia was in the pars membranacea with structurally normal cartilage, they referred to a study wherein cartilage from one patient with a presumed case of tracheomalacia was compared with that from the airway of a healthy person.4 Distinguishing tracheomalacia from DAC is essential as DAC appears to be a benign condition, whereas tracheomalacia tends to progress.35
Therefore, drastic interventions such as surgical splinting, placation, or even tracheal stenting must be reconsidered in individuals with DAC. In such situations, conservative measures such as therapy with bronchodilators, treatment of underlying infection, or perhaps treatment with positive airway pressure devices should be considered the primary therapy. This paradigm should minimize the number of unnecessary procedures performed.
References
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Correspondence to: Armin Ernst, MD, FCCP, BIDMC/Harvard Medical School, Boston, MA 02215; e-mail: aernst{at}bidmc.harvard.edu
To the Editor:
We thank Drs. Park and Edell for their kind words and suggestions as they relate to our article on tracheomalacia.1 It is correct that some dictionaries may define tracheomalacia as a weakness of the supporting cartilage, but most clinicians and the scientific literature in general are not in agreement with that proposal: when searching the term tracheomalacia in a medical literature search rather than a dictionary, this distinction is not followed.
Contrary to the assumption outlined in the comments, there is actually no need to do so either. It is the opinion of the authors that the article quoted by Park and Edell2 is insufficient to offer a definition for a new disease entity or even derive paradigms for treatment algorithms: the reference is a retrospective review of bronchoscopy forms without prior defined end points and follow-up or description of any other appropriate workup. Dynamic airway collapse should remain a descriptive term rather than a name for a disease.
We also contend that aggressive interventions are very well suited for select patients with tracheomalacia due to posterior membrane collapse. Those are actually the patients who may benefit the most from procedures such as tracheoplasty.34 In the end, it is not an issue of definition but where the choke point of the hyperdynamic obstruction is located that will dictate which interventions are feasible and what treatment algorithms should be followed.
References
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