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2. Electron beam 1. Short scanning time of only 50–100 ms allows 1. Might miss very short, focal abnormalities Advantages Disadvantages tomography for continuous acquisition of images of a 2. High radiation exposureal technique moving object 1. Poor display of anatomic detail of the 3. Clinical applicability is limited (labourve tracheal and paratracheal structures 2. Correlates well with symptoms and intensive, requiring 160 images/patient) 画像所見 2. Unable to display simultaneouslybronchoscopic ﬁndings the anteroposterior and lateral walls of the airway 3.Cine magnetic Operator dependent 1. Non-invasive high-resolution imaging with 1. Very limited clinical experienceumetric acquisition of data at both 1. Paired standard dose inspiratory-dynamic soft tissue contrast resonance imaging excellentration and during dynamic expiration expiratory multislice helical CT potentially of ionizing radiation 2. Absence trapping 3. Identiﬁcation of vascular structures without doubles radiation dose compared with Respirology (2006) 11, 388–406display of anatomic detail of the airway single-phase acquisition iodinated contrast media ent structures 4. Allows repeated assessments of the airway 深吸気時の胸部XPや胸部CTでは診断は困難.ective interpretation and quantitativement of the degree of collapse lumen during multiple respiratory maneuvers ous display of the anteroposterior teral walls of the trachea and allows ction of three-dimensional images well with bronchoscopy ﬁndingsnning time of only 50–100 ms allows 呼気, 吸気時の画像評価で気管支径の変化を追う方法, 1. Might miss very short, focal abnormalities uous acquisition of images of a 2. High radiation exposurebject well with symptoms and Cine ﬂuoroscopyによる評価, 気管支鏡による評価が有用 3. Clinical applicability is limited (labour intensive, requiring 160 images/patient)copic ﬁndingssive high-resolution imaging with 1. Very limited clinical experiencesoft tissue contrast f ionizing radiationtion of vascular structures without 吸気-呼気の気管左右径の変化値が contrast mediapeated assessments of the airway ring multiple respiratory maneuvers 上気道で18%以上, 中気道で28%以上ならば, TBMの可能性は89-100%, 上記(-)ではTBMは0-5%のみ. Figure 2 Right antero-oblique view ﬂuoroscopic image during inspiration (A) and expiration (B) shows expiratory collapse of the trachea (arrows) in a patient with severe tracheobron- chomalacia (TBM) due to post- pneumonectomy syndrome. Dynamic CT reveals normal tra- cheal calibre during inspiration (C) and collapse of the anterior tracheal wall resulting in severe crescent type TBM during expira- tion (D) from the same patient.
CSA − minimum CSA)/maximum CSA) × 100%) was upright and lateral decubitus positions and during signiﬁcantly higher in patients with tracheomalacia spontaneous breathing as well as during various Respirology (2006) 11, 388–406気管支鏡所見 than in healthy volunteers during forced inspiration and expiration and during coughing. maneuvers such as cough, forced expiration, deep inspiration. During these examinations changes in bronchial and tracheal calibre can be measured, extent of collapse is noted, narrowing can be classi- Bronchoscopy ﬁed as being of the crescent, saber-sheath type or cir- cumferential type, cartilaginous weakening (TBM) Bronchoscopy has been traditionally used to diag- can be differentiated from EDAC, and other abnor- 直視下で気管内の動きが観察できるため, nose TBM and EDAC although these entities are rarely described in terms of extent, severity, location and malities may be discovered (Fig. 3). The lack of a standard method to quantify the associated anomalies. Although both rigid and ﬂexi- severity of the airway collapse has made serial stud- 診断のGold Standardとなる. 狭窄の程度, タイプも分かる ble bronchoscopy can be performed, ﬂexible bron- choscopy is preferable for diagnosis because the ies, evaluation of therapies and comparisons between patients difﬁcult. In an effort to eliminate operator- patient is able to breathe spontaneously and follow biased descriptions and to improve the accuracy of TBM 吸気 EDAC 吸気 全周性TBM TBM 呼気 EDAC 呼気 三日月型TBM
Fig. 1. Distal trachea (A), left main bronchus (B), and right main bronchus (C) before stent insertion. In this patient, excessive dynamic airwayFig.collapse was caused by bulging bronchus (B), and right main bronchus (C) before stent mainstem bronchi (E) lumens completely restored 1. Distal trachea (A), left main of the posterior airway membrane. Lower trachea (D) and insertion. In this patient, excessive dynamic airwaycollapsestent caused by bulging of the posterior airway membrane. Lower trachea (D) and mainstem bronchi (E) lumens completely restored after was insertion. Respir Care 2007;52(6):752–754
Tracheobronchial stenting 8 K h a b wTBMのFlow-vol curve f Y 2 f p 閉塞性障害を来すが, In s a 特異的とは言えない. 0 s t Thorax 1996;51:224-226 t a s o C s D Flow-volume loop before (hatched line) and after (solid I line) tracheal stenting. c a
Respirology (2006) 11, 388–406TBM and EDAC TBM, EDACの治療 399Table 3 Proposed treatment modalities for tracheobronchomalacia and excessive dynamic airway collapseTreatment Advantages DisadvantagesMedical management 1. Bronchodilators • Useful in mild cases of EDAC due to • May worsen airﬂow obstruction caused by asthma and COPD TBM or EDAC alone 2. CPAP • Decreases pulmonary resistance • Intermittent treatment • Improves airﬂow obstruction • Limited experience • Decreases inspiratory work of breathing • May not sufﬁce as a stand alone therapy for severe cases 3. Disease speciﬁc drug • May sufﬁce in less severe cases due to • Concomitant CPAP and/or stent placement therapy asthma, COPD or RP often necessaryMinimally invasive surgery 1. Endolumenal airway stents • Improve symptoms and PFT • Limited data for isolated TBM or EDAC • Maintain airway patency • Stent related complications • Therapeutic trial before surgery • Often, multiple stents are required 2. Experimental approaches • Improvement in symptoms, • Preliminary results in a few patients PFT and bronchoscopic aspects laser therapyOpen surgery 1. Tracheostomy • Stents the airways • Tracheomalacia and stenosis at the stoma site • If necessary, provides invasive ventilatory • May exacerbate TBM/EDAC support 2. Airway splinting • Consolidates and reshapes the airway wall • Invasive, requires thoracotomy • Offers long-term airway support • Complications common with Marlex mesh 3. Tracheal resection • May be curative for focal malacia • Experience limited to specialized centres application and efﬁcacy in humans 4. Experimental approaches • Less complications than other techniques • Remains unknown in animal models EDAC, excessive dynamic airway collapse; PFT, pulmonary function tests; RP, relapsing polychondritis; TBM,tracheobronchomalacia.
thelium and normal cartilaginous growth.115 ever, suggest improvement in symptoms, ven Respirology (2006) 11, 388–406Diagnostic and management algorithm for tracheobronchomalacia (TBM) and excessive dynamic airway