Not all that wheezes is asthma: A case report of diffuse tracheobronchomalacia in an adult

Diffuse tracheobronchomalacia (DTBM), a separate entity to localised tracheobronchomalacia, refers to a disorder of the entire trachea and main bronchi where there is increased compliance of large airway cartilage leading to airway collapse in expiration. We report a rare case of DTBM in a patient with brittle asthma and demonstrate the importance of recognising this as a disorder that can present in adults with airways disease. CASE REPORT A 43 year old lady presented to clinic with a history of lifelong asthma that had become difficult to control over the preceding two decades despite maximal treatment including long-term steroids. CT imaging showed a crescentic trachea and slit-like main bronchi suggesting dynamic airways collapse. ![Figure][1] DTBM was confirmed on bronchoscopy. DISCUSSION DTBM is diagnosed via dynamic CT or bronchoscopy and is defined by 50% or more reduction in airway diameter in expiration. Adult DTBM can be asymptomatic or cause cough, recurrent infections and wheeze. The cause of acquired DTBM in the absence of intrinsic cartilage defects, is unclear but chronic airway inflammation is thought to play a role. In severe cases, treatment options include nocturnal CPAP and Y-stent insertion. This lady declined potential stenting deeming risks greater than the potential benefits. This case shows the importance of CT scans in assessing patients with difficult asthma in secondary care and how easily missed DTBM can be. [1]: pending:yes