B80-1-11 Not All That Wheezes Is Asthma: A Rare Case of Tracheomalacia

Abstract Introduction Tracheomalacia (TM) is an under-recognized condition in adults, characterized bydynamic collapse of the tracheal airway due to weakness of the tracheal wall, often leading to recurrent wheezing, cough, and respiratory infections. Because its symptoms overlap with more common entities such as asthma and chronic obstructive pulmonary disease (COPD), the diagnosis is frequently delayed, resulting in repeated ineffective therapies and increased morbidity. This case underscores the importance of including TM in the differential diagnosis when respiratory symptoms persist despite standard management. Case Description A 57-year-old man with a medical history of heart failure with reduced ejection fraction (25 %), COPD, and a prior cardiopulmonary arrest due to mucus plugging presented with persistent shortness of breath, productive cough and wheezing despite multiple courses of antibiotics for presumed respiratory infections. Computed tomography of the chest revealed mucus plugging of left lobar and segmental airways, narrowing of bronchi and flattening of the anteroposterior diameter of the trachea— findings suggestive of tracheomalacia versus tracheal stenosis. Although relapsing polychondritis was initially considered, absence of tracheal wall thickening and presence of cartilaginous portions of the airway argued against that diagnosis. Bronchoscopic evaluation confirmed over 80% tracheal collapse during inspiration and complete (100%) collapse during expiration, consistent with severe tracheomalacia. An infectious work-up (respiratory pathogen panel,COVID/flu PCR, bronchoalveolar lavage cultures) was negative. Management was directed toward airway clearance using incentive spirometry, mucolytics, and chest physiotherapy.The patient was referred for outpatient continuous positive airway pressure (CPAP) titration and interventional pulmonology evaluation for potential tracheal stenting. Discussion Adult tracheomalacia is a rare but clinically significant cause of persistent wheeze and infection not responsive to standard asthma or COPD therapies. The gold-standard diagnostic test remains bronchoscopy demonstrating dynamic airway collapse; dynamic CT imaging is useful as a non-invasive screening tool. Management is multifaceted:optimize underlying pulmonary disease, enhance airway clearance, and consider mechanical airway support (e.g., CPAP, airway stenting) for severe cases. Early recognition and tailored therapy can prevent complications including recurrent infections, bronchiectasis and respiratory failure. This case highlights the need for heightened clinical suspicion of tracheomalacia in adult patients with persistent wheezing and recurrent infections despite appropriate therapy. Conclusion Clinicians should broaden their differential diagnosis when confronted with persistent wheeze and respiratory infections resistant to conventional treatment. Though uncommon, tracheomalacia is a treatable condition whose timely diagnosis and intervention can markedly improve patient outcomes. This abstract is funded by: None