Airway Problems in Neonates—A Review of the Current Investigation and Management Strategies

Abstract

Airway problems in the neonatal population are often life threatening and raise challenging issues in diagnosis and management. The airway problems can result from congenital or acquired lesions and can be broadly classified into those causing obstruction or those due to an abnormal “communication” in the airway. Many different investigations are now available to identify the diagnosis and quantify the severity of the problem, and these tests can be simple or invasive. Bronchography and bronchoscopy are essential to determine the extent and severity of the airway problem and to plan treatment strategy. Further imaging techniques help to delineate other commonly associated abnormalities. Echocardiography is also important to confirm any associated cardiac abnormality. In this review, the merits and disadvantages of the various investigations now available to the clinician will be discussed. The current therapeutic strategies are discussed, and the review will focus on the most challenging conditions that cause the biggest management conundrums, specifically laryngotracheal cleft, congenital tracheal stenosis, and tracheobronchomalacia. Management of acquired stenosis secondary to airway injury from endotracheal intubation will also be discussed as this is a common problem. Slide tracheoplasty is the preferred surgical option for long-segment tracheal stenosis, and results have improved significantly. Stents are occasionally required for residual or recurrent stenosis following surgical repair. There is sufficient evidence that a multidisciplinary team approach for managing complex airway issues provides the best results for the patient. There is ongoing progress in the field with newer diagnostic tools as well as development of innovative management techniques, such as biodegradable stents and stem cell-based tracheal transplants, leading to a much better prognosis for these children in the future.

ERS statement on tracheomalacia and bronchomalacia in children

“…Tracheobronchography performed with low volumes of nonionic water-soluble contrast is safe [67], and useful in the evaluation of TBM because of its high spatial and temporal resolution (figure 2) [68]. Many centres continue to use tracheobronchography [12,67,[69][70][71], often in combination with flexible bronchoscopy [68]. Free breathing, as with many of the imaging techniques, is required for diagnostic accuracy [72].…”

Tracheal opening manoeuvre (PEEP-20) in a patient with bronchopulmonary dysplasia and severe tracheobronchomalacia with neurally adjusted ventilatory assist (NAVA)

“…Ventilatory management of tracheostomised patients with severe tracheomalacia is not adequately described in the medical literature. Using continuous positive airway pressure (CPAP) through tracheostomy is recommended in patients for long periods of time or when associated bronchomalacia is not suitable for surgery or stenting of the airway 6. Using the NAVA ventilation mode allowed us to achieve a better adaptation of our patient to the ventilator.…”

A case of neonatal bronchomalacia, manifesting as severe poorly resolving bronchopneumonia

“…Many different investigations are available to diagnose and quantify the severity 2 . HRCT chest with 3D reconstruction angiogram may help demonstrate the airway and vascular anatomy providing useful data in planning surgery 2,4 . Moreover, bronchography, with and without positive end expiratory pressure (PEEP) provides dynamic information as CT underestimates presence of bronchomalacia in terms of extent and the severity and facilitate the determination of required PEEP to keep the airways open ( Figure 2).…”

“…Airway problems in neonates are often life threatening and raise challenging issues in diagnosis and management 1,2 . These could be classified as congenital or acquired lesions and congenital obstructive lesions can be intrinsic lesion in the airway, external compression or maldevelopment of the airway 2 .…”

“…Airway problems in neonates are often life threatening and raise challenging issues in diagnosis and management 1,2 . These could be classified as congenital or acquired lesions and congenital obstructive lesions can be intrinsic lesion in the airway, external compression or maldevelopment of the airway 2 . Congenital bronchomalacia is a form of maldeveloped airway resulting in collapse of floppy cartilaginous portion of the airway 3 and is defined as "More than 50% dynamic collapse of the airways lumen, in the large right or left main-stem bronchi, and/or their respective divisions at the lobar or segmental bronchi, recorded at the end-expiratory point" 3 .…”