Excessive dynamic airway collapse leading to cardiac arrest due to airway obstruction

Abstract

An 85-year-old woman (body mass index 30.7 kg/m²), a never-smoker with a two-year history of a seal-like barking cough, presented with sudden-onset dyspnea. Examination revealed a respiratory rate of 21 breaths/min, expiratory wheezing, and an oxygen saturation of 90% on room air. Chest radiography revealed superior mediastinal widening with rightward tracheal deviation (Figure 1A), later attributed to an incidental thoracic aortic aneurysm. Computed tomography revealed pronounced posterior tracheal membrane collapse (Figure 1B) in the absence of emphysema. Shortly after imaging, the patient experienced a severe coughing episode, followed by stridor, choking, and cardiac arrest. Spontaneous circulation was restored after one cardiopulmonary resuscitation cycle and emergency intubation. Fiberoptic bronchoscopy (Video S1), performed with pressure support (positive end-expiratory pressure of 5 cm H₂O), showed a normal trachea during inspiration (Figure 1C) and pronounced posterior wall bulging during expiration (Figure 1D). These findings confirmed severe excessive dynamic airway collapse (EDAC), implicated in the cardiac arrest. On day 11, an uncovered self-expanding metallic stent was placed in the trachea, enabling successful extubation.

EDAC, often underdiagnosed, can mimic or coexist with inflammatory airway diseases.¹ It is characterized by expiratory collapse of the posterior membranous tracheal wall, hypothesized to result from an imbalance between intraluminal and pleural pressures, exacerbated by reduced wall tone and pressure drops caused by the Bernoulli effect in tapering airways,² particularly when elastic recoil is reduced.^{3, 4}

The authors declare no conflicts of interest.

Approval of the research protocol: None.

Informed consent: Published with the written consent of the patient.

Registry and the registration no. of the study/trial: None.

Animal studies: None.