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Tracheomalacia

Flaccidity of the trachea, due to injury or congenital defect, such that the tracheal passageway fails to stay open at its normal diameter, especially during inspiration. In adults, tracheomalacia is most commonly seen after a prolonged intubation in which the endotracheal tube balloon was (sometimes necessarily) over-inflated and, consequently, exerted too much pressure on the tracheal rings, damaging and thereby weakening them; infection can also exacerbate this weakening of the tracheal rings. Intubation is a less common cause of tracheomalacia now, however, since the advent years ago of high-volume, low-pressure endotracheal tube and tracheotomy tube cuffs. In neonates, tracheomalacia can be congenital or a sign of incomplete development of the trachea.

Tracheomalacia should be distinguished from nonorganic breathing disorder, tracheal, which differs from tracheomalacia in that the tracheal collapse which occurs is functional or volitional, and is sometimes used to amplify asthmatic wheezing, or to masquerade as asthma, in each case for secondary gain.

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narrowed trachea

Tracheomalacia (1 of 2)

Even at its maximum functional caliber, this trachea is severely narrowed (stenotic), due to injury from long-term intubation and tracheotomy. Not yet visible here is the tracheomalacia component (illustrated in image 2). A small granuloma is also visible on the right edge of the image.
Tracheomalacia

Tracheomalacia (2 of 2)

Additional functional collapse (the tracheomalacia component), with both inspiration and expiration.

Tracheal Hyperflexibility

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normal abduction of the vocal cords

Tracheal hyperflexibility (1 of 6)

This patient has COPD as well as a "wet and productive" sounding cough. The explanation for this is not actual mucus, but tracheal vibration that sounds like a mucus-y cough. This panoramic view shows inspiration and normal abduction of the vocal cords. As we will see in photo 3, the trachea is patent at this moment.
Tracheal hyperflexibility

Tracheal hyperflexibility (2 of 6)

Expiratory partial closure of the true vocal cords, similar to the lip-pursing maneuver persons with COPD often use to prevent lower airway collapse. As we see in photo 4, collapse is happening in spite of this lip-pursing maneuver.
Mid-trachea

Tracheal hyperflexibility (3 of 6)

Mid-trachea during deep inspiration, corresponding to the vocal cord position in photo 1. The white arrow indicates a speck of mucus which will also be seen in photo 4.
expiration in the mid-trachea

Tracheal hyperflexibility (4 of 6)

Mid-trachea, showing the same position as photo 3 but now during expiration. The membranous tracheal wall is bulging inward and nearly blocking the trachea. A wheezing sound is heard as air whistles though this narrow lumen (the expected lumen is indicated by the curved dotted line). The same speck of mucus that was seen in photo 3 is indicated again by the white arrow.
inspiration in the trachea

Tracheal hyperflexibility (5 of 6)

A little farther down the trachea, during inspiration.
Tracheal hyperflexibility

Tracheal hyperflexibility (6 of 6)

At the same position as photo 5, during a cough. The membranous trachea not only bulges inward, but it also vibrates impressively (note blur), creating a deep and rumbling cough whose "wet" quality is not actually from mucus, but from vibration of the tracheoesophageal party wall.
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