A 67-year-old woman with a BMI of 31.8 kg m2 presented to our outpatient clinic with productive refractory cough (worse on exertion), wheezing, and shortness of breath. Her past medical history was significant for asthma, gastroesophageal reflux disease, obstructive sleep apnea on CPAP, and recurrent pulmonary infections.
Dynamic computed tomography suggested severe expiratory collapse of the trachea, mainstem bronchi, and bronchus intermedius. Complementary findings with dynamic bronchoscopy showed collapsibility of 70% at the cricoid, 90% at mid trachea, 80% at distal trachea, 90% at right mainstem bronchus, 100% at bronchus intermedius, and 90% at left mainstem bronchus. These findings are consistent with severe ECAC in the subtype of EDAC, as portrayed in Fig. 1. Subsequently, a stent trial was attempted to assess surgical candidacy; however, it was not feasible due to complex anatomy consisting of a short epiglottis and anterior larynx.
Given the persistence of symptoms and quality of life impairment, an alternate method for surgical candidacy evaluation was pursued before committing the patient to TBP. We opted for pneumatic stenting of the airways during exercise.
We had the patient perform submaximal treadmill exercise (1.6 mph, 16% gradient) while CPAP was applied at 0 cmH2O (control), 9 cm H2O, and 11 cmH2O; each CPAP level was applied for 3 min (Fig. 2). At rest, the patient rated her 'exertion' (RPE) as 9 on the Borg 6-20 scale. Following the first 3 minutes of exercise at 0 cmH2O, the patient's RPE increased to 13. The exercise was also associated with worsening of the patient's cough. When applied at 9 cmH2O, the use of CPAP was associated with a decrease in RPE back to the baseline value and complete resolution of the patient's cough was achieved. Further titration of CPAP to 11 cmH2O was associated with a slight increase in RPE, but this could also reflect the duration of exercise and upward drift in heart rate rather than the lack of efficacy of the CPAP itself (Table 1). Overall, the patient and our team noticed a significant reduction in cough and shortness of breath when CPAP was applied, which led to the multidisciplinary joint decision to undergo surgical tracheal stabilization. TBP was performed without complications and resulted in an improvement of respiratory symptoms. Following this multidisciplinary management, the patient reported no recurrence of symptoms at a one-year follow-up.