3. D 前方の気管支軟骨の脆弱化 Respirology (2006) 11, 388–406
著明な三日月型となる.
C EDAC B 生理的呼気状態.
前後径が>50%縮小する場合 通常前後径は35%[11-61]縮小する
E 気管軟化症
左右径が縮小し, 剣の 状となる(Saber-sheath type)
11. 2. Electron beam 1. Short scanning time of only 50–100 ms allows 1. Might miss very short, focal abnormalities
Advantages Disadvantages
tomography for continuous acquisition of images of a 2. High radiation exposure
al technique moving object
1. Poor display of anatomic detail of the 3. Clinical applicability is limited (labour
ve tracheal and paratracheal structures
2. Correlates well with symptoms and intensive, requiring 160 images/patient)
画像所見
2. Unable to display simultaneouslybronchoscopic findings
the
anteroposterior and lateral walls of the airway
3.Cine magnetic
Operator dependent 1. Non-invasive high-resolution imaging with 1. Very limited clinical experience
umetric acquisition of data at both 1. Paired standard dose inspiratory-dynamic soft tissue contrast
resonance imaging excellent
ration and during dynamic expiration expiratory multislice helical CT potentially of ionizing radiation
2. Absence
trapping 3. Identification of vascular structures without
doubles radiation dose compared with Respirology (2006) 11, 388–406
display of anatomic detail of the airway single-phase acquisition iodinated contrast media
ent structures 4. Allows repeated assessments of the airway
深吸気時の胸部XPや胸部CTでは診断は困難.
ective interpretation and quantitative
ment of the degree of collapse
lumen during multiple respiratory maneuvers
ous display of the anteroposterior
teral walls of the trachea and allows
ction of three-dimensional images
well with bronchoscopy findings
nning time of only 50–100 ms allows
呼気, 吸気時の画像評価で気管支径の変化を追う方法,
1. Might miss very short, focal abnormalities
uous acquisition of images of a 2. High radiation exposure
bject
well with symptoms and Cine fluoroscopyによる評価, 気管支鏡による評価が有用
3. Clinical applicability is limited (labour
intensive, requiring 160 images/patient)
copic findings
sive high-resolution imaging with 1. Very limited clinical experience
soft tissue contrast
f ionizing radiation
tion of vascular structures without
吸気-呼気の気管左右径の変化値が
contrast media
peated assessments of the airway
ring multiple respiratory maneuvers 上気道で18%以上, 中気道で28%以上ならば,
TBMの可能性は89-100%, 上記(-)ではTBMは0-5%のみ.
Figure 2 Right antero-oblique
view fluoroscopic image during
inspiration (A) and expiration
(B) shows expiratory collapse
of the trachea (arrows) in a
patient with severe tracheobron-
chomalacia (TBM) due to post-
pneumonectomy syndrome.
Dynamic CT reveals normal tra-
cheal calibre during inspiration
(C) and collapse of the anterior
tracheal wall resulting in severe
crescent type TBM during expira-
tion (D) from the same patient.
14. CSA − minimum CSA)/maximum CSA) × 100%) was upright and lateral decubitus positions and during
significantly higher in patients with tracheomalacia spontaneous breathing as well as during various
Respirology (2006) 11, 388–406
気管支鏡所見
than in healthy volunteers during forced inspiration
and expiration and during coughing.
maneuvers such as cough, forced expiration, deep
inspiration. During these examinations changes in
bronchial and tracheal calibre can be measured,
extent of collapse is noted, narrowing can be classi-
Bronchoscopy fied as being of the crescent, saber-sheath type or cir-
cumferential type, cartilaginous weakening (TBM)
Bronchoscopy has been traditionally used to diag- can be differentiated from EDAC, and other abnor-
直視下で気管内の動きが観察できるため,
nose TBM and EDAC although these entities are rarely
described in terms of extent, severity, location and
malities may be discovered (Fig. 3).
The lack of a standard method to quantify the
associated anomalies. Although both rigid and flexi- severity of the airway collapse has made serial stud-
診断のGold Standardとなる. 狭窄の程度, タイプも分かる
ble bronchoscopy can be performed, flexible bron-
choscopy is preferable for diagnosis because the
ies, evaluation of therapies and comparisons between
patients difficult. In an effort to eliminate operator-
patient is able to breathe spontaneously and follow biased descriptions and to improve the accuracy of
TBM 吸気 EDAC 吸気 全周性TBM
TBM 呼気 EDAC 呼気 三日月型TBM
15. Fig. 1. Distal trachea (A), left main bronchus (B), and right main bronchus (C) before stent insertion. In this patient, excessive dynamic airway
Fig.collapse was caused by bulging bronchus (B), and right main bronchus (C) before stent mainstem bronchi (E) lumens completely restored
1. Distal trachea (A), left main of the posterior airway membrane. Lower trachea (D) and insertion. In this patient, excessive dynamic airway
collapsestent caused by bulging of the posterior airway membrane. Lower trachea (D) and mainstem bronchi (E) lumens completely restored
after was insertion. Respir Care 2007;52(6):752–754
16. Tracheobronchial stenting
8 K
h
a
b
w
TBMのFlow-vol curve f
Y
2
f
p
閉塞性障害を来すが, In
s
a
特異的とは言えない. 0
s
t
Thorax 1996;51:224-226 t
a
s
o
C
s
D
Flow-volume loop before (hatched line) and after (solid I
line) tracheal stenting. c
a
17. Respirology (2006) 11, 388–406
TBM and EDAC TBM, EDACの治療 399
Table 3 Proposed treatment modalities for tracheobronchomalacia and excessive dynamic airway collapse
Treatment Advantages Disadvantages
Medical management
1. Bronchodilators • Useful in mild cases of EDAC due to • May worsen airflow obstruction caused by
asthma and COPD TBM or EDAC alone
2. CPAP • Decreases pulmonary resistance • Intermittent treatment
• Improves airflow obstruction • Limited experience
• Decreases inspiratory work of breathing • May not suffice as a stand alone therapy for
severe cases
3. Disease specific drug • May suffice in less severe cases due to • Concomitant CPAP and/or stent placement
therapy asthma, COPD or RP often necessary
Minimally invasive surgery
1. Endolumenal airway stents • Improve symptoms and PFT • Limited data for isolated TBM or EDAC
• Maintain airway patency • Stent related complications
• Therapeutic trial before surgery • Often, multiple stents are required
2. Experimental approaches • Improvement in symptoms, • Preliminary results in a few patients
PFT and bronchoscopic aspects laser therapy
Open surgery
1. Tracheostomy • Stents the airways • Tracheomalacia and stenosis at the stoma
site
• If necessary, provides invasive ventilatory • May exacerbate TBM/EDAC
support
2. Airway splinting • Consolidates and reshapes the airway wall • Invasive, requires thoracotomy
• Offers long-term airway support • Complications common with Marlex mesh
3. Tracheal resection • May be curative for focal malacia • Experience limited to specialized centres
application and efficacy in humans
4. Experimental approaches • Less complications than other techniques • Remains unknown
in animal models
EDAC, excessive dynamic airway collapse; PFT, pulmonary function tests; RP, relapsing polychondritis; TBM,
tracheobronchomalacia.
18. thelium and normal cartilaginous growth.115 ever, suggest improvement in symptoms, ven
Respirology (2006) 11, 388–406
Diagnostic and management algorithm for tracheobronchomalacia (TBM) and excessive dynamic airway
