B80-1-09 Beyond Asthma: A Tracheal Tale

Abstract Introduction Wheezing due to airflow obstruction is a classic sign of asthma. However, structural airway diseases can present similarly, leading to misdiagnosis and inappropriate treatment. We present a case of a patient misdiagnosed and treated for severe asthma for years, ultimately found to have tracheobronchopathia osteoplastica (TPO), a rare tracheal disorder causing fixed and dynamic airway obstruction. Description Case Presentation A 67-year-old male patient was referred to clinic with a 6-year history of recurrent cough, wheezing, dyspnea and poorly controlled asthma despite being on multiple asthma medications. He reported more than six hospital admissions for asthma exacerbations requiring systemic steroids and antibiotics. His spirometry had consistently shown severe airway obstruction, his treatment included ICS, antileukotrienes, allergen immunotherapy, and anti-IL5 receptor, benralizumab. He also reported a history of vocal cord paresis which was previously managed by ENT. Given the lack of response, on his initial visit, dupilumab was initiated awaiting further diagnostic work-up. Chest-CT revealed mild tracheal dilation, and repeat spirometry showed moderate-severe fixed airway obstruction with expiratory loop flattening, raising concern for dynamic airway collapse. He was therefore referred for bronchoscopy, which revealed enlarged tracheal rings with osteophytes and complete anteroposterior distal tracheal collapse, consistent with TPO. Due to ongoing symptoms, airway stenting was initially considered but was deemed due to feasibility. He was therefore referred to a specialized center and underwent tracheobronchoplasty with mesh placement via right thoracotomy. Within 2 months following his procedure, the patient showed marked clinical improvement, with normalization of lung function and stepwdown de-escalation of hid asthma therapy, leading to complete discontinuation of biologics and maintenance inhaler. At follow-up during the following two years, he remained asymptomatic, with only mild chronic cough, and required no rescue asthma medications. Discussion This case highlights the critical need to reassess a presumed asthma diagnoses in patients who continue to be symptomatic despite maximal standard of care therapy especially those who present with fixed airway obstruction and atypical progression. While TPO is a rare condition, its ability to mimic severe asthma can result in years of misdiagnosis and ineffective treatment.The recognition of persistent expiratory flow limitation accompanied by flattened flow-volume loopsshould raise early suspicion for underlying structural upper airway disorders. In such cases, dynamic CT imaging of the chest as well as bronchoscopy are essential with the latter remaining the definitive diagnostic tool to uncover conditions like TPO and to prevent delays in appropriate management. This abstract is funded by: None