Anomalies in the development of the trachea and bronchi: causes, symptoms, diagnosis, treatment

Acquired deviations of the trachea and bronchi proceed without significant changes in their lumen. Most often, bronchial deviations occur due to external pressure of the tumor or cyst located in the lung parenchyma. Tracheal deviations are usually caused by pressure from volumetric formations or by traction of scars originating in the upper mediastinum. Deviations can be temporary and permanent.

Temporary deviations of the trachea and bronchi are due to the difference in pressure in the mediastinum arising on both sides of the organ, for example, with partial or total atelectasis of one of the lungs. Radiography determines the displacement of the trachea and bronchi toward atelectasis, and in the case of fluoroscopy, the Holzknecht-Jacobson phenomenon is observed, consisting of tracheal and bronchial oscillations in time to the respiratory movements. Endoscopically this phenomenon is manifested by atypical excursions of the keel of the trachea, which is displaced during inspiration towards the affected lung with insufficient air filling (Mounier-Kuhn symptom). With a rapid filling of the pleural cavity with effusion or air, the mediastinum initially shifts to a healthy side, carrying with it the trachea and bronchi. These signs are less pronounced in mediastinal tumors.

If these factors causing a secondary displacement of the trachea and bronchi quickly pass, then the mediastinal organs occupy their normal position.

Constant or chronic deviations of the trachea and bronchi are manifested by the same external signs as temporal deviations, they differ only in a prolonged course and in the occurrence of secondary inflammatory reactions. Usually, chronic deviations of the trachea and bronchi arise as a result of cicatricial processes in the pleural cavity, lung tissue and mediastinum caused by corresponding purulent-inflammatory banal or specific diseases. The main symptom of such deviations is the lack of respiratory function during physical exertion. The diagnosis is easily established by fluoroscopy or radiography with contrast.

The narrowing of the lumen of the trachea and bronchi, resulting from their external compression, regardless of the cause that caused it, causes a violation of the circulation of the air flow and the phenomenon of chronic hypoxic hypoxia. Initial signs of these phenomena occur when the area of the lumen of the trachea decreases by 3/4 and progressively increases with further narrowing of its lumen. The narrowing of the lumen of the bronchus determines the respiratory function, depending on the caliber of the bronchus.

Of the neoplasms of the mediastin, which cause compression of the trachea, the first to be named are those that grow into the trachea and narrow its lumen with its volume. Compression of the bronchi is due primarily to adenopathies, neoplasms and atelectasis of the lung, including artificially induced by the method of collapsotherapy. Of the adenopathies, most commonly causing compression of the trachea and bronchi, are banal microbial adenopathy, metastatic adenopathy, adenopathy with lymphogranulomatosis, etc. The compression of the middle part of the trachea can be caused by the defeat of the thyroid gland, hyperplastic lymph nodes, embryonic tumors, diverticula and foreign bodies of the esophagus, aneurysm of the aorta, pleurisy, tumors of the pleura and lungs, abscesses and phlegmon of the mediastinum, etc.

The main symptoms are increasing in intensity and duration of cough and dyspnea. When involved in the process of the recurrent nerve - a violation of voice formation, manifested by a bitonal voice sound. The general condition of the patient depends on the cause that caused the airway compression, and on the degree of respiratory failure.

Diagnosis is established by X-ray examination. Tracheobronchoscopy with a rigid instrument is contraindicated.

Tracheobronchial fistulas. Tracheobronchial fistulas are the messages of the cavity of the trachea and bronchi with the surrounding organs and tissues that have arisen as a result of a number of destructive processes both in the lower respiratory tract and outside them.

Fistulas of lymph nodes. In the overwhelming majority of cases, these fistulas develop due to tuberculous lesions of the lymph nodes immediately adjacent to the trachea or bronchus. With this arrangement of the lymph nodes, the caseous-necrotic process proceeding in it passes to the wall of the trachea or bronchus, destroys it, resulting in the formation of a tracheobronchial-lymphatic fistula. The formation of such a fistula can occur in two forms - acute and prolonged.

The acute form is characterized by a sudden and massive breakthrough of caseous masses into the trachea or main bronchus, which causes a rapidly growing gasp: the patient becomes very anxious, becomes pale, then cyanotic, loses consciousness, and only urgent intubation of the trachea or tracheotomy with suction of the blocked airways of detritus and purulent masses can save him from death.

The protracted shape is characterized by a less turbulent clinical development of obstruction of the trachea and bronchi, which depends on the degree of evacuation of caseous masses penetrating the lumen of the respiratory tract. With this form, repeated tracheobronchoscopy with removal of purulent sputum, washing the cavity of the trachea and bronchi, and the introduction of complex antibiotic drugs are effective.

The melting of the affected lymph node that formed the fistula and draining it through the fistula or scarring it with subsequent calcination leads to the healing of the fistula with the possible formation of stenosis of the affected bronchus or trachea.

Tracheophistinal fistulas occur more often than described above, and are mainly caused by esophageal damage. Most often these fistulas arise at the points of contact between the trachea and the left main bronchus with the esophagus, which facilitates the transition of the inflammatory-destructive process from one organ to another. It is also possible to indirectly transfer the pathological process, through the affected lymph node.

Among the reasons for the formation of tracheoesophageal fistulas, cancer and purulent inflammation of the lymph node are in first place. With endoscopy of the trachea or bronchus, this fistula is a granuloma or rosette formed from a granulation tissue, partially overlapping the lumen of the airway formation. When water is swallowed in the trachea or bronchus, water can leak; When esophagoscopy during expiration, especially with straining, air bubbles enter the esophagus.

If the respiratory function is disturbed, these formations coagulate with diathermy or are cauterized with chemicals.

Other causes that cause tracheobronchial fistulas include deep chemical burns of the esophagus, penetrating foreign bodies, especially with their late recognition, tuberculosis and syphilitic granulomas, purulent esophagitis, etc. Spontaneous aero-esophageal fistulas arising in the late period of inflammatory lesions of the esophagus and trachea or bronchus, as a result of their cicatricial degeneration and thinning. Usually, such fistulas occur with strong natuzhivanii (constipation, lifting significant weight, a sharp sneeze or a violent cough).

Often, the diagnosis and treatment of pulmonologists, phthisiatricians and thoracic surgeons are bronchopleural perforations, post-operative bronchial fistulae, which most often occur with partial lobectomy, fistula tracheas, which appear as a complication of the medulla phlegmon.

Anomalies in the development of the trachea and bronchi. These anomalies may long remain unrecognized and can be detected by routine examination of the lower respiratory tract.

Congenital esophageal and tracheal fistula, as a rule, are small, falling behind the fold of the mucous membrane of the esophagus, which plays the role of a protective valve, which explains the meager symptomatology of this defect (periodic cough with phlegm).

Congenital dilatation of the trachea and bronchi is an extremely rare malformation of the lower respiratory rods; sometimes due to congenital syphilis. Clinical manifestations are expressed in frequent catarrhal tracheobronchitis, propensity to bronchoectations, hypersensitivity to respiratory infections.

The syndrome of Kartagener is a complex of autosomal recessive hereditary anomalies:

1. bronchiectasis with chronic bronchitis, relapsing pneumonia and bronchorrhea;
2. chronic sinusitis with nasal polyposis and rhinorrhea;
3. situs viscerum inversus.

Radiographically, sachet fields of enlightenment, shading of the paranasal sinuses, intergrown ribs, cervical ribs, spina bifida, congenital heart defects, infantilism, plurigundular insufficiency, dementia, fingers in the form of drumsticks are determined radically in the lung.

Tracheal (accessory) bronchi: the additional bronchus departs directly from the trachea, above the bifurcation.

Anomalies of branchings and distributions of bronchi. Most often occur in the area of the lower lobe of the lung, do not disrupt the respiratory function.

Absence of half of the lower respiratory tract, combined with the absence of an appropriate lung.

Tracheomalacia is a rare phenomenon, like laryngomalacia, in the thinning and weakness of the cartilages of the trachea, which are distinguished by considerable compliance with tracheoscopy. Areas of tracheomalacia can occur in the area of the keel, in the area of the entrances to the bronchi or on any part of the tracheal wall. As a rule, tracheomalacia is combined with the same anomaly of bronchial development. Clinically, this defect of the lower respiratory tract manifests itself in a constant dyspnea, often with crises of hypoxic hypoxia, up to asphyxia with fatal outcome.

Treatment of the above-described anomalies in the development of the lower respiratory tract is exclusively palliative and symptomatic, with the exception of congenital tracheal fistula that can be eliminated by endo-esophageal microsurgical intervention.

[1], [2], [3], [4], [5]