Tracheomalacia is a condition where the walls of the trachea (windpipe) are abnormally floppy instead of rigid, causing the airway to collapse during breathing. Normally, your trachea is held open by 16 to 20 horseshoe-shaped rings of firm cartilage. In tracheomalacia, those rings are too soft or damaged, so the airway narrows when air pressure changes during breathing. A collapse greater than 50% of the trachea’s diameter is enough to obstruct airflow and cause noticeable symptoms.
How the Trachea Normally Works
The trachea is essentially a tube connecting your voice box to your lungs, reinforced by cartilage rings that form a U-shape. The front and sides are rigid cartilage; the back wall is a flexible membrane shared with the esophagus. This design lets you breathe freely while still allowing some flex when you swallow food. A small amount of tracheal collapse during forceful breathing is completely normal. In infants, the trachea can temporarily narrow by up to 30% of its diameter during a strong exhale without causing any problems.
In tracheomalacia, the cartilage rings are either underdeveloped or weakened, so the trachea loses its semicircular shape. The back membrane bulges inward, the front-to-back diameter shrinks, and airflow drops. Even a small reduction in the airway’s opening causes a disproportionately large drop in airflow, which is why symptoms can seem outsized compared to what’s visible on imaging.
Congenital vs. Acquired Tracheomalacia
The condition comes in two broad forms. Congenital (primary) tracheomalacia is present from birth and results from cartilage that simply hasn’t matured properly. It most often affects the lower third of the trachea and is the more common form seen in infants. Babies born prematurely are at higher risk because their cartilage has had less time to develop.
Acquired (secondary) tracheomalacia develops later in life when something damages or compresses previously healthy cartilage. Common causes include prolonged intubation (a breathing tube pressing against the tracheal wall), chronic inflammation from conditions like relapsing polychondritis, compression from enlarged blood vessels or tumors near the airway, and complications following tracheal surgery. In adults, chronic obstructive pulmonary disease (COPD) and long-term tobacco use are also associated with acquired forms.
What It Feels Like
The hallmark symptom is a harsh, barking cough that sounds almost seal-like. Because the floppy airway vibrates as air moves through it, breathing can produce stridor, a high-pitched, noisy sound. Where in the trachea the collapse happens determines when the noise occurs: if the weak segment sits inside the chest cavity, the airway collapses mostly during exhaling. If it’s higher up, near the neck, the collapse happens during inhaling.
In mild cases, noisy breathing may be the only sign, and it often gets louder during crying, feeding, or respiratory infections. More significant cases involve wheezing that doesn’t respond to asthma medications, recurrent chest infections because mucus gets trapped behind the collapsed segment, and difficulty feeding in infants. Symptoms tend to worsen when a child has a cold or upper respiratory infection, because the added mucus and inflammation further narrow an already compromised airway.
Severe Complications
Most cases of tracheomalacia are mild. But in severe forms, the airway can collapse almost completely, leading to episodes sometimes called “dying spells” or “blue spells.” During these events, the child turns blue (cyanotic), stops breathing briefly, and in rare cases can experience cardiac arrest or sudden death. These episodes can be triggered by something as ordinary as food passing through the esophagus and pressing on the softened trachea, a buildup of secretions, or the increased chest pressure from straining or coughing. Recurrent pneumonia is another complication, since a collapsing airway traps mucus that becomes a breeding ground for bacteria.
How It’s Diagnosed
Tracheomalacia can be tricky to catch on standard imaging because the collapse is dynamic, meaning it only happens during certain phases of breathing. A regular X-ray or CT scan taken at a single moment may look normal.
The gold standard for diagnosis is flexible bronchoscopy, a procedure where a thin, lighted camera is guided into the airway while the patient is breathing spontaneously (not paralyzed by anesthesia). This lets the doctor watch the trachea in real time and see exactly where and how much it collapses. Dynamic CT scanning, which captures images during both inhaling and exhaling, is an alternative that can measure the airway’s diameter at its widest and narrowest points.
Severity is graded by the percentage of collapse observed. The European Respiratory Society uses a three-tier scale: 50% to 74% collapse is mild, 75% to 89% is moderate, and 90% to 100% (where the airway walls touch each other) is severe.
Treatment for Mild Cases
The good news for parents of infants with congenital tracheomalacia: most children outgrow it. As the tracheal cartilage matures and the airway grows larger, the noisy breathing and respiratory difficulties gradually resolve, typically by age two to three. During that waiting period, management focuses on keeping respiratory infections under control, using humidified air to loosen secretions, and careful positioning during feeding to reduce the chance of reflux compressing the airway.
For adults with mild acquired tracheomalacia, treatment often targets the underlying cause. If COPD or chronic inflammation is driving the cartilage damage, managing those conditions can reduce symptoms. Continuous positive airway pressure (CPAP), the same type of device used for sleep apnea, can help by providing a constant stream of air pressure that acts as an internal splint to keep the trachea open.
When Surgery Is Needed
Surgery becomes necessary when tracheomalacia causes life-threatening apnea spells, cyanosis, an inability to come off a ventilator, feeding difficulties that affect growth, or recurrent pneumonia. One of the most common procedures in children is aortopexy, where the aorta (the large blood vessel that sits near the trachea) is stitched to the back of the breastbone. This pulls the front wall of the trachea forward and opens the airway without touching the trachea itself.
For localized areas of collapse, a tracheal stent, a small mesh tube placed inside the airway, can hold the weakened segment open. Stenting is more common in adults and carries its own risks, including the stent shifting position or tissue growing over it. In the most severe cases where a short segment of trachea is damaged beyond repair, surgical removal of that segment and reconnection of the healthy ends (tracheal resection) may be an option.
Living With Tracheomalacia
For children with mild to moderate forms, day-to-day life usually involves managing flare-ups rather than constant symptoms. Respiratory infections will temporarily make breathing noisier and harder, so prompt treatment of colds and flu matters more than it would for other kids. Keeping up with vaccinations, especially against flu and respiratory syncytial virus (RSV), helps reduce the frequency of these flare-ups.
Adults with acquired tracheomalacia often notice that symptoms are worst during exercise or when lying flat. Sleeping with the head slightly elevated and using CPAP at night can make a significant difference. Avoiding irritants like cigarette smoke, strong chemical fumes, and very cold, dry air also helps minimize episodes of airway collapse.