The Tracheobronchomalacia (TBM) Program at Brigham and Women’s Hospital offers a team-based approach to the diagnosis and treatment of TBM. We combine the expertise of different specialists working together to offer you the best possible care.
Our TBM program offers:
- New techniques to diagnose TBM (airway oscillometry and density-dependence of maximal expiratory flow)
- Advanced surgical approaches that lead to a shorter recovery time after surgery and less pain
- Collaborative, team-based care from specialists such as pulmonary (lung) medicine specialists, thoracic surgeons, interventional pulmonologists, radiologists and anesthesiologists
- Clinical research that leads to innovations in how we care for patients
- Long-term supportive care and follow-up
What is tracheobronchomalacia (TBM)?
Tracheomalacia is an airway disorder where the trachea (windpipe) is floppy or abnormally collapsible. Sometimes the main bronchial tubes (airways in the lungs) are also abnormally floppy and the broader term tracheobronchomalacia (TBM) is used.
TBM can happen in one of two ways:
- The membrane and supportive tissue at the back of your trachea weaken. As a result, when you breathe out, this part of the trachea and main bronchi (breathing tubes) bulges into the air tubes. It partially blocks the passage of air and mucus. When the airway becomes narrowed by 80-90 percent, breathing becomes difficult.
- TBM can also happen if a disease causes the firm supporting wall at the front and sides of your trachea (which is made of cartilage, a type of flexible tissue) to become soft and weak.
What are the symptoms of TBM?
Symptoms can include:
- A severe cough that doesn’t go away
- Wheezing (especially when breathing out)
- Shortness of breath
- Phlegm that easily gets stuck in the windpipe
Sometimes the cough associated with TBM has a particular sound. However, the symptoms of TBM are often very similar to the symptoms of other common airway diseases, such as asthma, bronchitis and chronic obstructive pulmonary disease (COPD). This means your doctor may need to run additional tests to diagnose TBM and rule out other conditions with similar symptoms.
What are risk factors for tracheobronchomalacia (TBM)?
People of any age or background can get TBM. Most often the cause of TBM is unknown. In some cases, risk factors include:
- A prior tracheostomy (surgery on the trachea)
- Prolonged mechanical ventilation. This is machine-assisted breathing in an intensive care unit (ICU).
- Pre-existing illnesses. These include certain autoimmune or inherited diseases, like relapsing polychondritis (RP), amyloidosis and Munier-Kuhn syndrome. RP is an autoimmune condition that causes painful inflammation in cartilage and tissues throughout the body. Amyloidosis is when abnormal proteins called amyloids build up and form deposits. The deposits can collect in organs like the lungs, heart and kidneys. Munier-Kuhn syndrome is a lung disorder that causes the respiratory tract to dilate or enlarge.
How common is tracheobronchomalacia (TBM) in the population?
No one knows exactly how common TBM is in the general population because mild cases don’t cause symptoms. Also, not all doctors have been trained to diagnose TBM because diseases like asthma and COPD that can mimic TBM are much more common.
How is TBM diagnosed?
There are certain tests your doctor may recommend.
- Computed tomography (CT) – A CT scan (also called a CAT scan) uses special equipment to make a series of detailed, cross-sectional images from different angles. This method is the traditional imaging technique for TBM. To diagnose TBM, the CT scan is done in a special way. Images are collected when you breathe in and then again when you breathe out. This lets the CT scan see if your airways are collapsing when you exhale.
- Fiberoptic bronchoscopy – This technique uses a thin, flexible tube with a camera at the end of it to look directly inside your trachea and bronchial tubes. It is considered the “gold standard” diagnostic test and there is minimal risk to the procedure.
- Pulmonary (lung) function tests – Testing is done to find out the impact of TBM on how well the lungs are working. Finding out how much TBM affects your breathing can be tricky. At Brigham and Women’s Hospital, we offer specialized pulmonary tests (called airway oscillometry and density-dependence of expiratory flow) to determine to what extent TBM is causing your shortness of breath.
- Advanced imaging techniques – Video CT imaging and cine MR (magnetic resonance) are among the novel radiographic imaging techniques being explored at Brigham and Women’s Hospital.
How is tracheobronchomalacia (TBM) treated?
Because TBM is a structural problem, surgery is needed to repair it. This repair surgery is called a tracheoplasty. Traditionally, surgery has required a major chest incision. At Brigham and Women’s Hospital, we offer a minimally-invasive approach that avoids large incisions. Our minimally invasive surgery has less risk, less pain following surgery and a much shorter recovery time than traditional surgery. Our new approach uses robotic surgery, which is when your surgeon uses special instruments that can make tiny incisions.
Is surgery for tracheobronchomalacia (TBM) appropriate for everyone?
No. We have a standard approach to find out who is a good candidate for surgery. To find out if TBM surgery (tracheoplasty) can help improve your symptoms, we temporarily place a stent (plastic tube) inside the central airways. The stent sits inside your windpipe and its main branches and prevents these airways from collapsing when you breathe out. If the stent resolves your breathing problems, you will most likely benefit from TBM surgery. Because stents can irritate the tracheal wall if they are used long term, they can’t be left in permanently. Tracheoplasty surgery is the long-term solution for TBM. Symptoms like cough, shortness of breath, wheezing and trouble clearing excess secretions from the airways usually improve after the surgery.
What if the stent doesn’t work for me, or if surgery isn’t the best fit for me?
There are medical options that can help treat TBM, although they don’t cure it.
Treatments may include:
- Medicines to open the airways as much as possible. These medicines are called bronchodilators.
- Using equipment (like plastic, hand-held devices) to help clear secretions from the lungs, especially in the context of respiratory tract infections. These are called positive expiratory pressure (PEP) bronchial vibrating devices.
- Air pressure applied from a face mask (called a CPAP mask) that can help to hold open the windpipe. CPAP stands for continuous positive airway pressure. The CPAP mask is the same mask people with sleep apnea may use at night. Sleep apnea is a sleep disorder that affects breathing patterns.
What is a tracheobronchomalacia (TBM) consultation like?
If you are coming from afar, we can arrange for coordinated initial consultations on the same day. Pulmonary (lung) function testing and possible placement of a tracheal stent (a stent trial) will be scheduled if needed.
We offer:
- A close communication with the doctor who referred you
- Complete testing and treatment as needed
- Case review by our multidisciplinary team
- Long-term follow-up if you need it
Are patients seen for tracheobronchomalacia (TBM) only in the Longwood Medical Area in Boston?
Our team-based consultation, specialized testing and surgeries are performed at Brigham and Women’s Hospital in the Longwood Medical Area in Boston. However, you can also make appointments with our TBM experts at Brigham and Women’s Faulkner Hospital in Jamaica Plain, Brigham and Women’s Ambulatory Care Center in Chestnut Hill and Patriot Place in Foxboro.
TBM Program Team
Pulmonary Medicine:
Interventional Pulmonology:
Thoracic Surgery:
Radiology:
Anesthesiology:
