Etiology and Management of Tracheomalacia: Experience with 37 Children

Abstract

Tracheomalacia (TM) is a recognized cause of stridor in infancy and childhood. Its link to chronic respiratory failure in children is also known.1 Although laryngomalacia is considered the most common cause of upper airway obstruction in children, TM is increasingly being diagnosed either as an intrinsic deficiency of tracheal structure 2,3 or secondary to a spectrum of surgical lesions of the mediastinum, chest wall and the esophagus. 4 One study considers bronchopulmonary dysplasia (BPD), following prolonged ventilation for hyaline membrane disease, to be the most frequent reason for "primary" tracheomalacia. 5Of increasing interest is TM's association with esophageal atresia (EA). A number of reviews have emphasized its significance in children who suffer recurrent pulmonary problems after the repair of tracheoesophageal fistula. 6,7 There have also been advances in the field of diagnostics, i.e., fiberoptic endoscopy, and cine CT scan, 8,9 and surgical treatment by aortopexy has improved the survival and prognosis of many critically ill children with TM. 10Our interest in the subject was triggered by two surgical children. One of them had EA repaired as a newborn, but continued to suffer from recurrent attacks of pneumonia and apneic spells. Following the diagnosis of TM and aortopexy at the age of 18 months, he improved partially. The other child had aberrant innominate artery, apparently compressing the trachea; exploration did not establish this as the cause, but subsequent bronchoscopy showed TM.In this paper we describe our experience with tracheomalacia from 1986 to 1994 at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, with a brief review of its etiology and management. Patients and MethodsWe reviewed the records of 45 infants and children in whom one of the discharge diagnosis (ICD-9 World Health Organization) was tracheomalacia. Eight were excluded: in seven the diagnosis of TM was suspected but not proven on bronchoscopy, and in one, the child became asymptomatic after the excision of bronchogenic cyst even though bronchoscopic findings suggested TM.The information recorded included the diagnosis on admission; the age at diagnosis of TM; indication for assisted ventilation and the period of ventilation; associated anomalies; the results of imaging, including esophagogram, CT scan and angiography when performed; timings and findings on bronchoscopy, and the outcome. The patients were classified as primary or secondary tracheomalacia according to groups proposed by Benjamin in 1984 11 and modified by Greenholz et al. in 1986. 12 Only descriptive statistics were used for calculating average, range and standard deviation. ResultsThe ages of children, at the time TM was diagnosed, ranged from 21 days to 38 months, with an average age of 8.5 (SD 9.8) months (median=5; range=0-38). Male to female ratio was equal.Thirty out of 37 children were primary with abnormality confined to the trachea alone: the admission diagnoses were prematurity and hyaline membrane disease (HMD) in 15, meconium...