Primary bronchomalacia in infants and children☆,☆☆
Section snippets
CASES
Summaries of the cases of 17 patients with primary bronchomalacia and tracheobronchomalacia are included in the Table. All patients but one were seen in the pulmonology clinic of the Children's Hospital of Pittsburgh and resdie in western Pennsylvania.
Patient No. Sex Age at diagnosis History Examination Bronchoscopic finding Duration of follow-up Follow-up result Other 1 M 5.5 mo “Congested breathing” since birth; intermittent wheezing with colds Right-sided wheeze
OVERVIEW
Bronchomalacia refers to chondromalacia of a main-stem bronchus. It can be found in association with tracheomalacia (tracheobronchomalacia). The affected bronchus lacks rigidity because of insufficient cartilage or extrinsic compression. During quiet respiration, small changes in the diameter of the affected bronchus can be inapparent on physical examination. Forced expiration will cause collapse of the nonrigid portion of the bronchus and can result in a wheeze that is often audible without a
History
Historical findings in patients with bronchomalacia are fairly consistent. All patients have symptoms within the first 6 months of life, with “noisy breathing” and a harsh wheeze on forceful expiration. Many parents do not note the wheeze until the infant's first cold. All infants have coughing and wheezing with colds and continue to have symptoms between colds. The breathing is generally quiet in sleep. The diagnosis of gastroesophageal reflux is often entertained before the diagnosis of
TREATMENT
A twofold therapeutic approach to these patients, mechanical and pharmacologic, is useful. To improve clearance of the affected side in the younger infants, parents can turn the affected side of the infant upward during sleep—allowing for the lung with poor clearance to drain into the normal side, which then can clear secretions normally. All parents should learn chest physiotherapy and perform it when their children have colds. Gravitational drainage techniques are useful when the patient has
NATURAL HISTORY
The presence or absence of small-airways hyperreactivity partly determines the course of this disorder. In general, patients without RAD in general have a smoother course and gradually outgrow the symptoms of large-airway obstruction. Between birth and maturity, the trachea and bronchi double in length and triple in diameter. It is the tripling of the airway diameter that is responsible for the resolution of daily symptoms. All three patients with primary bronchomalacia older than 5 years of
CONCLUSION
Primary bronchomalacia and tracheobronchomalacia are much more common than was previously thought. Bronchomalacia and tracheobronchomalacia should be considered in the infant with persistent wheezing and should be evaluated. Failure of standard antiasthma therapy is a clue that the wheezing appreciated on examination may reflect an anatomic obstruction of the central airway. An absence of hyperinflation in the face of wheezing on examination also suggests central airway obstruction. The natural
Acknowledgements
I am indebted to David M. Orenstein, MD, for his critical reading of the manuscript and for his encouragement and advice. I also gratefully acknowledge Mr. Steve Walczak and Ms. Rebecca Mutich for technical assistance with the bronchoscopies.
References (20)
Left mainstem bronchopexy for severe bronchomalacia
J Pediatr Surg
(1991)Association between pectus excavatum and segmental bronchomalacia
J Pediatr
(1980)Localized tracheomalacia or bronchomalacia in children with intractable cough
J Pediatr
(1990)- et al.
Segmental bronchomalacia: success-ful surgical correction in an infant
J Pediatr Surg
(1985) Pediatric respiratory disease
(1993)Spelunking in the pediatric airways: explorations with the flexible fiberoptic bronchoscope
Pediatr Clin North Am
(1984)The diagnostic effectiveness of the flexible bronchoscope in children
Pediatr Pulmonol
(1985)
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Reprint requests: Jonathan D. Finder, MD, Children's Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA 15213.
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