Abstract Background Tracheomalacia (TM) is an underrecognized cause of persistent respiratory symptoms in cystic fibrosis (CF), particularly when clinical features overlap with asthma. Both conditions can lead to dynamic airway collapse, impaired secretion clearance, and recurrent pulmonary exacerbations. Failure to distinguish TM from asthma may delay appropriate interventions, including surgical airway stabilization. Case Presentation A 4 child with CF dF508/dF508 and presumed moderate-persistent asthma presented with recurrent exacerbations despite guideline-directed therapy. Over the preceding year, the patient required three hospitalizations, multiple courses of systemic corticosteroids, and had persistent exertional dyspnea, chronic cough, and “noisy breathing.” Asthma therapy included high-dose inhaled corticosteroids, long-acting bronchodilator, leukotriene receptor antagonist, and as-needed short-acting bronchodilators, while airway clearance regimens and CF care were optimized. Response to bronchodilators remained limited. Persistent symptoms out of proportion to asthma severity prompted airway evaluation. Flexible bronchoscopy demonstrated severe (75%) dynamic tracheal collapse, most pronounced in the mid-trachea. Dynamic CT confirmed marked anteroposterior airway collapse without fixed stenosis. The case was reviewed by pulmonology, otolaryngology, and pediatric surgery, and surgical intervention was recommended due to symptom severity and functional impact. The patient underwent posterior tracheopexy with external tracheal support without perioperative complications. Asthma therapy was gradually de-escalated postoperatively based on clinical response. Outcome At 12-month follow-up, the patient experienced no hospitalizations for pulmonary exacerbations, compared with three in the prior year. Significant improvements were noted in cough strength, mucus clearance, exercise tolerance, and sleep quality. Caregivers reported marked improvement in daily functioning and quality of life. Asthma medication burden decreased, and symptoms were well-controlled with low-intensity therapy. Discussion This case illustrates that TM may masquerade as refractory asthma in CF. When clinical symptoms remain disproportionate to asthma therapy response, evaluation for dynamic airway collapse should be considered. Multidisciplinary assessment is crucial to guide intervention. Surgical tracheal stabilization may provide substantial benefit when conservative therapy is insufficient. Conclusion and Learning Points • TM should be considered in CF patients with recurrent exacerbations or poor asthma control despite optimized therapy. • Bronchoscopy and dynamic imaging can clarify the contribution of TM to respiratory symptoms. • Surgical airway stabilization may improve outcomes and reduce healthcare utilization in selected patients. This abstract is funded by: none
Arevalo et al. (Fri,) studied this question.