Management of tracheobronchomalacia with continuous positive airway pressure

doi:10.1016/S0022-3468(85)80471-1

Journal of Pediatric Surgery

Volume 20, Issue 5, October 1985, Pages 489-493

https://doi.org/10.1016/S0022-3468(85)80471-1 Get rights and content

Three infants presenting with respiratory distress required early ventilator support. With attempts at extubation recurrent airway obstruction occurred. The clinical course was marked by recurrent episodes of hyperinflation, atelectasis, and pneumonia. Bronchoscopy, bronchography, and chest fluoroscopy revealed extensive collapse of the trachea and main stem bronchi. Two of the infants had gastroesophageal reflux and recurrent aspiration. Treatment of tracheobronchomalacia (TBM) was carried out with a tracheostomy tube attached to a portable CPAP apparatus. Initially CPAP was maintained at 10 cm of water and subsequently weaning was achieved by gradual decreasing of both positive pressure and hours of treatment per day. Total treatment time ranged from 13 to 25 months. Feedings were carried out via gastrostomy. Two infants with severe gastroesophageal reflux underwent fundoplication. Each infant was successfully weaned from distending pressure and decanulated. The treatment of sever TBM with long-term CPAP appears to be a reasonable alternative or adjunct to surgical procedures such as tracheopexy, resection, external splinting and tracheobronchoplasty.

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Cited by (67)

Interventionnal bronchoscopy for the treatment of tracheobronchomalacia
2023, Revue des Maladies Respiratoires
Le collapsus trachéobronchique expiratoire regroupe la trachéobronchomalacie, maladie des anneaux cartilagineux et le collapsus dynamique excessif des voies aériennes, bombement majeur de la membraneuse au niveau la paroi postérieure. La symptomatologie repose sur des signes respiratoires peu spécifiques comme la dyspnée, la toux ou les difficultés d’expectoration. Le diagnostic est obtenu lors d’épreuves dynamiques, par l’endoscopie bronchique et/ou le scanner. La trachéobronchomalacie peut être primaire (génétique, idiopathique) ou secondaire liée à un traumatisme, une trachéotomie, une intubation, une intervention chirurgicale, une transplantation, un emphysème, une infection, une inflammation, une bronchite chronique, une compression extrinsèque ou à des anneaux vasculaires non diagnostiqués dans l’enfance. Certains algorithmes décisionnels thérapeutiques ont été proposés, mais aucune recommandation précise n’a été établie. Le traitement, d’abord médical (prise en charge de la pathologie sous-jacente, parfois associée à la ventilation non invasive), est réservé aux malades symptomatiques, après évaluation du retentissement de la maladie (statut fonctionnel et perfomance status du malade, évaluation des symptômes et de la qualité de vie par différents scores). Si les symptômes persistent, d’autres traitements sont discutés. Au sein de l’arsenal thérapeutique, la bronchoscopie interventionnelle permet : (1) la sélection des malades pouvant bénéficier du traitement chirurgical de référence, avec la mise en place d’une endoprothèse comme test thérapeutique avant trachéobronchoplastie ; (2) la pose d’endoprothèses dans les voies aériennes chez les malades non chirurgicaux, dans le but d'obtenir une amélioration des symptômes et de la qualité de vie, au prix d’effets secondaires majeurs liés aux endoprothèses ; (3) la prise en charge de la majorité des complications associées aux endoprothèses (obstruction, granulomes, migration fracture) ; (4) des alternatives thérapeutiques avec la possibilité de techniques thermo-ablatives. Enfin, le développement de nouvelles endoprothèses pourrait permettre de diminuer le taux de complications. Ces différentes options restent encore très discutées à l’heure actuelle.
Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.
ISHLT Consensus Statement on adult and pediatric airway complications after lung transplantation: Definitions, grading system, and therapeutics
2018, Journal of Heart and Lung Transplantation
Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications varies widely, contributed to by the lack of a universally accepted grading system and standardized definitions. Furthermore, the majority of the existing classification systems fail to integrate the wide range of possible bronchial complications that may develop after lung transplant. Hence, a Working Group was created by the International Society for Heart and Lung Transplantation with the aim of elaborating a universal definition of adult and pediatric airway complications and grading system. One such area of focus is to understand the problem in the context of a more standardized consensus of classifying airway ischemia. This consensus definition will have major clinical, therapeutics, and research implications.
Surgical Disorders of the Chest and Airways
2018, Avery's Diseases of the Newborn: Tenth Edition
The embryologic development of the chest and airways is complex and errors in prenatal development can lead to an extensive variety of congenital malformations in both the upper and lower respiratory tract. Among these disorders, there is a wide range in the severity of the malformation with some being uniformly fatal while others are more of a nuisance. The prompt diagnosis of these disorders is key in recognizing the problem and working towards a treatment. Many of the disorders of the airways and chest are now diagnosed prenatally with the increasing accuracy of prenatal sonography. Early prenatal diagnosis not only allows for appropriate parental counseling during pregnancy but in some cases allows for prenatal interventions including both in utero interventions and planned ex utero intrapartum treatments (EXIT). For those infants born with disorders of the chest and airways, the interventions to correct these anomalies have become increasingly less invasive. Thoracoscopic and endoscopic techniques have been refined and adapted to address multiple disorders including sequestrations, CPAMS, congenital diaphragmatic hernias and complex chest wall disorders. These minimally invasive techniques have revolutionized the treatment of these disorders and made the surgical intervention on the infant airway and chest less invasive and more tolerable.
Manometry Optimized Positive Expiratory Pressure (MOPEP) in Excessive Dynamic Airway Collapse (EDAC)
2017, Respiratory Medicine
Positive expiratory pressure(PEP) breathing modalities are commonly prescribed in obstructive lung diseases, however practical methods of airway pressures(AP) quantification for therapeutic efficacy are lacking. Excessive dynamic airway collapse(EDAC) is characterized by expiratory central airway collapse leading to dyspnea and poor quality of life(QoL), with limited therapeutic options.
To measure AP and exertional dyspnea in EDAC patients during normal breathing and with use of pursed-lip breathing(PLB), nasal PEP device(nPEP), and oral-PEP valve(oPEP) during rest and exercise using an Esophageal Manometer.
EDAC patients exercised on a bicycle ergometer sequentially using normal breathing, PLB, nPEP, and oPEP for five-minute intervals. AP's were measured by continuous topographic upper airway manometry. Pre- and post-exercise BORG dyspnea scores were recorded and QoL measured with the St. George's respiratory questionnaire(SGRQ-C). The most effective and patient-preferred PEP modality was prescribed for daily activities and SGRQ-C repeated after one week.
Three women with symptomatic EDAC participated. Expiratory laryngopharyngeal AP's during exercise with normal breathing, PLB, nPEP and oPEP in patient-1 were 1.7, 14, 4.5, and 7.3 mmHg, in patient-2; 2.3, 8, 8.3, and 12 mmHg, and in patient-3; 1, 15, unobtainable, and 9 mmHg, respectively. Maximal reduction in BORG scores occurred with PLB in patient 1 and with oPEP in patients 2 and 3. After 1 week mean SGRQ-C scores declined by 17-points.
Upper airway manometry directly measures laryngopharyngeal pressures during rest and exercise and can be used to select and optimize PEP breathing techniques to improve respiratory symptoms in EDAC patients.
Tracheobronchomalacia
2017, Disease-a-Month
The term tracheobronchomalacia refers to excessively compliant and collapsible central airways leading to symptoms. Although seen as a coexisting condition with various other pulmonary condition, it may cause symptoms by itself. The condition is often misdiagnosed as asthma, bronchitis or just chronic cough due to a lack of specific pathognomonic history and clinical findings. The investigation revolves around different modes of imaging, lung function testing and usually confirmed by flexible bronchoscopy. The treatment widely varies based on the cause, with most cases treated conservatively with non-invasive ventilation. Some may require surgery or stent placement. In this article, we aim to discuss the pathophysiology behind this condition and recognize the common symptoms and causes of tracheobronchomalacia. The article will highlight the diagnostic steps as well as therapeutic interventions based on the specific cause.
Surgical Disorders of the Chest and Airways
2017, Avery's Diseases of the Newborn, Tenth Edition
The embryologic development of the chest and airways is complex and errors in prenatal development can lead to an extensive variety of congenital malformations in both the upper and lower respiratory tract. Among these disorders, there is a wide range in the severity of the malformation with some being uniformly fatal while others are more of a nuisance. The prompt diagnosis of these disorders is key in recognizing the problem and working towards a treatment. Many of the disorders of the airways and chest are now diagnosed prenatally with the increasing accuracy of prenatal sonography. Early prenatal diagnosis not only allows for appropriate parental counseling during pregnancy but in some cases allows for prenatal interventions including both in utero interventions and planned ex utero intrapartum treatments (EXIT). For those infants born with disorders of the chest and airways, the interventions to correct these anomalies have become increasingly less invasive. Thoracoscopic and endoscopic techniques have been refined and adapted to address multiple disorders including sequestrations, CPAMS, congenital diaphragmatic hernias and complex chest wall disorders. These minimally invasive techniques have revolutionized the treatment of these disorders and made the surgical intervention on the infant airway and chest less invasive and more tolerable.

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²: Presented at the Annual Meeting of the Canadian Association of Paediatric Surgeons, September 10–11, 1984, Montreal, Quebec, Canada.

¹: From the Sections of Pediatric Surgery and Pediatric Anesthesiology, Children's Hospital of Winnipeg, Manitoba, Canada.

View full text

Management of tracheobronchomalacia with continuous positive airway pressure2

J Pediatr Surg

J Pediatr Surg

J Thor Cardiovasc Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Tracheal dynamics in infants with respiratory distress, stridor, and collapsing trachea

Radiology

Bronchomalacia in children—Considerations governing medical vs surgical treatment

Clin Pediatr

Agenesis of the lung complicated by vascular compression and bronchomalacia

J Pediatr Surg

Generalized bronchiectasis due to extensive deficiency of bronchial cartilage

Arch Dis Child