BIDMC a national leader in diagnosing and treating tracheobronchomalacia
For all of his 46 years, Tom Garceau had enjoyed good health. But that ended abruptly one winter morning in 2010, when he suffered a bout of severe coughing that lasted an interminable 30 minutes. "I coughed so hard, I passed out several times," says Garceau, now 48, who lives and works in New Hampshire.
Thinking at first it was just a bad cold, Garceau, who has never smoked, went to his primary care doctor and, over the course of many months, to a number of specialists. Despite a variety of diagnoses, tests, treatments and even several hospitalizations, Garceau's relentless cough persisted. "I couldn't go for more than a few minutes without coughing, and I'd often get lightheaded. I couldn't watch TV without disrupting my family, carry on a conversation, or even drive because of the risk of passing out. It was disrupting my entire life," he says.
Eventually, in early 2012, Garceau - by then, at wits' end - was referred to Sidhu Gangadharan, MD, Chief of the Chest Disease Center (Division of Thoracic Surgery and Interventional Pulmonology) at BIDMC.
TBM is under-recognized
Many conditions can cause persistent cough, but because of Garceau's history, Gangadharan suspected tracheobronchomalacia (TBM). TBM is a condition of unknown cause in which the walls of the trachea and bronchi - the central airways - are weak and floppy. The Chest Disease Center evaluates and treats more patients for TBM than anyplace else in the U.S., and is widely considered the national leader in TBM care and outcomes research.
The most common symptom of TBM is shortness of breath. But many patients also have a distinctive seal-bark cough, recurrent infections, and build-up of secretions in the lungs. "TBM is under-recognized because many of the symptoms can be due to other respiratory conditions like asthma or COPD [chronic obstructive pulmonary disease]," says Gangadharan. "But treatment for these conditions will do nothing for TBM, which is an anatomic problem."
Although Garceau had undergone a slew of tests elsewhere, Gangadharan and his team started from square one to make certain of his diagnosis. While many tests are necessary, the mainstays for diagnosing TBD are computed tomography (CT) and/or flexible bronchoscopy performed while the patient forcefully exhales, a specialized maneuver refined at BIDMC that reveals the true extent of airway collapse, says Adnan Majid, MD, Director of Interventional Pulmonology.
The prevailing definition of TBM is a 50 percent reduction in the diameter of the airway. But Gangadharan and Majid look for complete or near complete (90 to 100 percent) collapse. "Some degree of collapse is normal," says Gangadharan. "It's important to differentiate normal from abnormal collapse to avoid overtreatment."
Many patients diagnosed with TBD may be helped with non-surgical interventions, such as pulmonary rehabilitation and/or CPAP (continuous positive airway pressure), although the latter is not a daytime therapy.
Some may benefit from the insertion of a stent into their airway to prop it open, but stents often cause irritation or infection after several weeks, limiting their effectiveness. Before he came to BIDMC, for example, Garceau had a stent inserted but it caused more problems than it solved and had to be removed.
Usually a stent is used for about two weeks as a "hypothesis tester," says Gangadharan. If breathing improves, the doctors know the problem is likely caused by airway collapse, not a condition within the lungs.
The only effective, permanent treatment for severe, diffuse TBM like Garceau's is an open surgical procedure called tracheobronchoplasty. During this operation, the surgeon sutures a section of mesh at multiple points on the outside of the floppy airway, which stabilizes it, much as a splint stabilizes a broken bone. The objective is to reconstitute the trachea's natural cross-sectional "D" shape and prevent its inner walls from intruding into the airway. The advantage of this approach is that nothing is left inside the airway to cause infection or trigger a reaction to a foreign body.
Garceau underwent a tracheobronchoplasty in the spring of 2012. His recovery from the operation was slow, but steady. Garceau still had a lingering cough resulting from a damaged larynx caused by many months of coughing, but it was effectively treated with medication by laryngologist Pavan Mallur, MD, Otolaryngology, who is part of the multidisciplinary TBM team.
Today, Garceau is thrilled to feel "normal" again. "I can ride my motorcycle, hike, and even have a conversation - all of which was impossible before," he says. Now able to exercise without fits of coughing, Garceau has also shed a lot of weight, improving his overall health.
"The care I got from Dr. Gangadharan, Dr. Majid, Dr. Mallur, and all the nurses at Beth Israel Deaconess was just incredible," says Garceau. "I'm so grateful to them for giving me my life back."