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TBM: Tracheobronchomalacia

Pioneer in Robotic Tracheobronchomalacia Repair Surgery

TBM:  Tracheobronchomalacia

Normally, our trachea and bronchial tubes expand by 30% when we inhale and will compress n diameter by 30 % when we exhale. ***


Excessive Central Airway Collapse, also know as ECAC, is a condition where the trachea and/or bronchial tubes compress by more than 70% during a forced exhalation. Excessive dynamic airway collapse (EDAC) is a form of ECAC when the cartilage portion of the trachea and bronchial tubes maintains its inherent structure and shape, and the back wall, also known as the posterior membrane is floppy and elongated and moves towards the front of the trachea causing airway collapse. *


A second subtype of ECAC is known as Tracheobronchomalacia (TBM), which involves a weakening of the cartilaginous trachea and bronchial tubes such that upon forceful exhalation the geometry the tracheal and bronchial changes from round and tubular on inhalation to flat, widened, and a slit-like opening that is often associated with an intractable cough, recurrent infections and shortness of breath*

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Screening for TBM and EDAC begins with a dynamic CT Scan of the Chest


After patients are evaluated and optimally treated for associated medical conditions, a special CT scan of the chest is obtained. A CT scan of the chest is normally performed with a patient taking a deep breath and holding their breath for a moment. In that instant, the CT scan machine is able to obtain precise images of the entirety of the chest including the trachea and bronchial tubes. During these inhalation acquired images, when the trachea and bronchial tubes are maximally expanded, the trachea and bronchial tubes may look relatively normal.*


The CT scan must also include additional images where the patient is coached by the technologist who is performing the scan to take a deep breath and exhale forcefully. It is during the exhalation that we are able to acquire images to compare the size and shape of the trachea and bronchial tubes and compare these observations and measurements to the standard images. This is useful in identifying both EDAC and TBM*

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Diagnosing TBM and EDAC involves a Bronchoscopy


### *Bronchoscopy is a procedure whihc is performed in the hospital by a surgeon or pulmonary specialist with monitired care by an anesthesiologist. Topical anesthesia is administered so that a small fiberoptic flexible camera, similar to one used by ENT physicians in the office, is able to be passed beyond the vocal cords so the physician can visualize in real time the extent and severity of the airway collapse so that a treatment plan can be developed to improve symptoms*

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Surgery for TBM


Surgery to repair the pathologically weakened airway in the symptomatic patient was first performed through a very large incision in 1954. Unfortunately, there is no medical treatment to correct TBM short of surgical repair. Until 2013, when Dr. Lazzaro performed the first robotically assisted airway repair, the repair was only offered to a few patients who were strong enough to undergo the open incision repair. Today, Dr. Lazzaro has published his results as well his technique, which has been adopted by some of the best thoracic surgeons in the world from the some of the best institutions who traveled to observe Lazzaro’s technique and bring it back to their instituitions. Postoperativley, patients will still need to be treated by their medical providers, which may include primary care physicians, pulmonologists and cardiologist, but patients enter the operating room with a failing airway (trachea and bronchial tubes) and leave with a rebuilt airway that has been reported to be associated with improvement in symptoms and lung function. *

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Publications on Tracheobronchomalacia


Lazzaro R, Bahroloomi D, Wasserman G, Patton B. Robotic Tracheoplasty Technique. Operative Techniques in Thoracic and Cardiovascular Surgery. Article in Press. Epub February 12, 2022. [https://www.optechtcs.com/article/S1522-2942(22)00007-1/fulltext](https://www.optechtcs.com/article/S1522-2942(22)00007-1/fulltext)


Lazzaro RS, Patton BD, Wasserman GA, Karp J, Cohen S, Inra ML, Scheinerman SJ. Robotic-assisted tracheobronchoplasty: Quality of life and pulmonary function assessment on intermediate follow-up. J Thorac Cardiovasc Surg. 2021 Jul 17:S0022-5223(21)01043-6. doi: 10.1016/j.jtcvs.2021.07.012. Epub ahead of print. PMID: 34340852.


Shah V, Husta B, Mehta A, Ashok S, Ishikawa O, Stoffels G, Hartzband J, Lazzaro R, Patton B, Lakticova V, Raoof S. I’m Association Between Inhaled Corticosteroids and Tracheobronchomalacia. Chest. 2020 Jun;157(6):1426-1434. doi: 10.1016/j.chest.2019.12.023. Epub 2020 Jan 21. PMID: 31978429.


Cohen SL, Ben-Levi E, Karp JB, Lazzaro RS, Shah A, Rahmani N, Shah RD. Ultralow Dose Dynamic Expiratory Computed Tomography for Evaluation of Tracheomalacia. J Comput Assist Tomogr. 2019 Mar/Apr;43(2):307-311. doi: 10.1097/RCT.0000000000000806. PMID: 30531547.


Lazzaro R, Patton B, Lee P, Karp J, Mihelis E, Vatsia S, Scheinerman SJ. First series of minimally invasive, robot-assisted tracheobronchoplasty with mesh for severe tracheobronchomalacia. J Thorac Cardiovasc Surg. 2019 Feb;157(2):791-800. doi: 10.1016/j.jtcvs.2018.07.118. Epub 2018 Nov 14. PMID: 30669239.


Lazar JF, Posner DH, Palka W, Spier LN, Lazzaro RS. Robotically Assisted Bilateral Bronchoplasty for Tracheobronchomalacia. Innovations (Phila). 2015 Nov-Dec;10(6):428-30. doi: 10.1097/IMI.0000000000000215. PMID: 26655932

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