Dynamic airway collapse: more questions than answers?

The vast majority of clinicians—pulmonologists, thoracic surgeons, and radiologists alike—have only a very general understanding of dynamic airway collapse. Identification in a patient—whether on bronchoscopy or computed tomography (CT) scan—typically gets filed away somewhere between “wow that’s impressive” and “someone else’s problem”. The relatively small subset of physicians who diagnose, treat, and critically think about this entity would be prudent to review the recent manuscript by Cho et al. in the Annals of Thoracic Surgery (1).

In “Tracheobronchoplasty for Excessive Dynamic Airway Collapse and Tracheobronchomalacia: A Comparative Analysis of Distinct Airway Disorders”, the authors present an excellent review of the anatomical, radiographic, and endoscopic distinctions between excessive dynamic airway collapse (EDAC) and tracheobronchomalacia (TBM), and present a proposed tailored approach to patients with these two conditions. This group of experts deserves distinct recognition for attempting to cast light on a complex and often misunderstood pathophysiological and anatomical syndrome.

In this single-center, retrospective case series review, 73 patients underwent tracheobronchoplasty for EDAC or TBM during a 5-year period. The diagnostic and therapeutic strategies were reviewed, as well as short- and long-term outcomes, with a proposed distinction between the two entities as it relates to an open versus robotic-assisted surgical approach. This review, from a group with extensive experience, is one of the largest series in managing this challenging patient population and provides a unique perspective on the subtle differences.

Despite the incredible value this study provides, several questions arise. Firstly, it is unnecessarily restrictive to limit CT scan reviews to representative cuts, which would never be utilized in real-world patient care. Although addressing the difficulty in diagnosing these entities, this does not seem practical and likely complicates an already complex diagnosis, contributing to the 12% lack of consensus. As diagnostic ambiguity remains a limiting factor in treating this condition, efforts should be made to expand available data rather than restrict it. Similarly, no mention of protocolized pre-operative bronchoscopy is made, although dynamic bronchoscopy while spontaneously ventilating with forced expiratory maneuvers has been previously reported as crucial to the diagnosis (2).

Even more importantly, there is no mention of a stent trial in this manuscript, while the authors themselves have previously reported the positive predictive value of symptomatic improvement on outcomes following surgical repair (3). Is there a distinction between EDAC and TBM when it comes to trialing a stent, or perhaps for prolonged stenting for therapeutic purposes? This remains unknown based on this series.

The suggested algorithm proposing an open surgical approach for TBM versus a robotic-assisted thoracoscopic approach for EDAC is of particular interest. A definitive recommendation on this point would be of significant value to the thoracic surgery community. However, we would argue this decision point would be further affected by (I) mesh choice and (II) pre-operative versus intra-operative mesh tailoring. The authors take for granted the use of polypropylene mesh, adopted by many other centers as well, although many mesh options are available (4). Is there a better mesh choice based on subtype of airway pathology?

Finally, there is no evidence to support the need to customize a mesh based on CT scans versus intra-operative findings, although the need for additional tension on weakened cartilage in TBM versus EDAC is reasonable. While these are valuable suggestions, taking these assumptions at face value weakens the proposed surgical algorithm.

We applaud Cho et al. for this excellent review, and recommend that all clinicians managing patients with TBM and EDAC closely study the pathophysiological and anatomical differences highlighted in this manuscript. However, many questions still remain regarding optimal patient management, and we call upon the thoracic surgery community to contribute their collective experience toward a greater understanding of this complex entity.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-63/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-63/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Cho JM, de Angelis P, Mathew F, et al. Tracheobronchoplasty for Excessive Dynamic Airway Collapse and Tracheobronchomalacia: A Comparative Analysis of Distinct Airway Disorders. Ann Thorac Surg 2025;120:1062-70. [Crossref] [PubMed]
2. Buitrago DH, Wilson JL, Parikh M, et al. Current concepts in severe adult tracheobronchomalacia: evaluation and treatment. J Thorac Dis 2017;9:E57-66. [Crossref] [PubMed]
3. Pan JM, Ospina-Delgado D, Kaul S, et al. Preoperative Workup of Patients With Excessive Central Airway Collapse: Does Stent Evaluation Serve a Role?. J Bronchology Interv Pulmonol 2024;31:146-54. [Crossref] [PubMed]
4. Lazzaro R, Inra ML. Tracheobronchoplasty: Indications and Best Approaches. Thorac Surg Clin 2023;33:141-7. [Crossref] [PubMed]