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Hosseini A, Sinaei R, Yeganeh MH, Boroujeni MG, Dara N, Sadr S, Iranikhah A, Rouzrokh M. A dual H-type tracheoesophageal fistula; why not being repaired simultaneously? A case report and review of literature. BMC Pediatr 2023; 23:308. [PMID: 37337161 DOI: 10.1186/s12887-023-03945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 03/06/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND H-type Tracheoesophageal Fistula (TEF) is a particular type of congenital esophageal anomalies, in which patients present with non-specific symptoms that can result in delayed diagnosis. Here, we report two pediatric cases with a rarer variant called ‟dual H-type TEFˮ. CASE PRESENTATION We present two cases of H-type TEF. The first was a 45-day-old boy with feeding problem and cyanosis while feeding, and the second was a three-month-old girl with cough and choking after feeding from the first day of birth. In both cases, two separate TEFs were detected during diagnostic evaluation by flexible bronchoscopy. Both were repaired simultaneously through a cervical incision. The first patient deteriorated 13 days after the surgery, disturbancing in acid-base balance and expired unfortunately. CONCLUSION Hence, it is necessary to consider the possibility of double TEF in any newly diagnosed H-type TEF.
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Affiliation(s)
- Amirhossein Hosseini
- Pediatric Gastroenterology, Hepatology and Nutrition Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Sinaei
- Department of Pediatrics, School of medicine, Kerman University of Medical Sciences, Kerman, Iran.
- Clinical Research Development Unit, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran.
| | | | | | - Naghi Dara
- Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Pediatric Gastroenterology, Hepatology and Nutrition, Tehran, Iran
| | - Saeed Sadr
- Mofid Children's Hospital, Department of Pediatric Pulmonology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abolfazl Iranikhah
- Qom University of Medical Sciences, Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Qom, Iran
| | - Mohsen Rouzrokh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Pediatric Surgery, Tehran, Iran
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2
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A New Removable Helical Metallic Stent for the Treatment of Tracheomalacia in Children: Study in Pathological Animal Model. J Clin Med 2022; 11:jcm11226757. [PMID: 36431234 PMCID: PMC9695607 DOI: 10.3390/jcm11226757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Congenital tracheomalacia is a pathology with no consensus of medical or surgical approach. The permanent nature and the major complications associated with metallic stents have limited their use over the years. The purpose of this study was to evaluate the feasibility of a helical stent design removal. METHODS Ten dogs diagnosed with tracheal collapse and treated with the helical stent were involved in the study. Animals were classified into three groups depending on stent indwelling time. Prior to the removal, endoscopic evaluation was performed to assess endothelization grade, mucous accumulation, and the presence of stenosis. During the removal, bleeding, fracture, or impossibility of removal were noted. After the removal, all macroscopic mucosal changes were recorded. RESULTS Technical success was 100%, without any complications. Complete epithelization of the stent was visualized in 7/10 animals. The removal procedure duration ranged from 2-12 min. At post-removal endoscopy, bleeding or epithelial damage, was visualized in any case. Stent fracture during removal occurred in one animal. CONCLUSIONS The removal of a metallic stent with spiral geometry is feasible, simple, and without complications, regardless of the degree of neo-epithelialization.
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3
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Paediatric tracheobronchomalacia: Incidence, patient characteristics, and predictors of surgical intervention. J Pediatr Surg 2022; 57:543-549. [PMID: 35718546 DOI: 10.1016/j.jpedsurg.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/08/2022] [Accepted: 05/06/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Tracheobronchomalacia (TBM), a condition where an abnormality of the tracheal walls causes collapse during the respiratory cycle, is a common cause of airway obstruction in childhood. TBM can present with a large spectrum of disease severity and underlying pathologies that may be managed medically and surgically, and it is not always clear which patients would most benefit from surgical intervention. We aim to describe the incidence, patient characteristics, and predictors of surgical intervention in a large cohort of paediatric patients. METHODS We performed a retrospective review of all children diagnosed with TBM to a paediatric Otolaryngology unit in the west of Scotland between 2010 and 2020. Odds ratios for clinical predictors of surgery were calculated using logistic regression with uni- and multivariate analysis. RESULTS 249 patients were identified of which 219 proceeded to data collection. Primary malacia was noted in 161 (73.5%) and secondary in 58 (26.5%). Causes of secondary malacia included compression by the innominate artery (11%) and vascular rings (7.8%). Surgical interventions were performed in 28 patients (12.8%) including division of vascular ring, aortopexy, and surgical tracheostomy. Multivariate analysis showed secondary TBM, acute life-threatening events, and difficulty weaning from mechanical ventilation were independent risk factors for surgical intervention. CONCLUSIONS TBM can present with a myriad of airway symptoms and is frequently associated with other airway and mediastinal pathologies necessitating multiple interventions. Children aged <1 year present with a more severe form of the disease and the presence of particular independent risk factors may indicate a need for surgical intervention.
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4
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Morante-Valverde R, Usategui A, López M, Grau M, Luna-Paredes MC, Albi S, Alonso-Riaño M, Pablos JL, Antón-Pacheco JL. Histological and structural effects of biodegradable polydioxanone stents in the rabbit trachea. Eur J Cardiothorac Surg 2022; 62:6628586. [PMID: 35781568 DOI: 10.1093/ejcts/ezac380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/03/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the potential biologic effects caused by successive placement of biodegradable polydioxanone (PDO) stents in the rabbit trachea. PDO stents could eventually induce a fibroproliferative reaction in the submucosa that could be beneficial in the treatment of malacia due to an increase in its consistency without impairing the tracheal lumen. METHODS Sixteen adult NZ rabbits were distributed into 3 groups with different survival times according to the number of stents placed: One stent (14 weeks), 2 stents (28 w.), and 3 stents (42 w.). Stent insertion was performed endoscopically in the cervical trachea of the animal. Histopathological studies included Masson's trichrome staining for submucosal fibrosis and Safranin O to assess structural integrity of cartilage. Potential inflammatory changes were analysed by means of immunohistochemistry determining the number of CD45 positive cells. RESULTS Stent placement was successful in every case. Histological studies did not show a statistically significant increase in tracheal wall collagen area and cartilage structure was not modified in those rabbits with one or more PDO stents inserted compared to non-stented tracheal sections. Furthermore, no statistically significant changes in the number of CD45+ cells were observed in stented tracheal segments compared to normal tracheal tissues. CONCLUSIONS According to our data, successive PDO stenting caused mild inflammatory changes in the tracheal wall, no increase in the collagen matrix, and the cartilaginous support was not modified during a long follow-up period (up to 42 weeks). These findings suggest that they may be safe and show good biocompatibility in the long-term.
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Affiliation(s)
- Rocío Morante-Valverde
- Pediatric Surgery Division & Pediatric Airway Unit. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Universidad Complutense de Madrid. Spain
| | - Alicia Usategui
- Inflammatory and Autoimmune Diseases Research Group. Instituto de Investigación Hospital U. 12 de Octubre (imas12). Avda. de Córdoba s/n, Madrid 28041. Spain
| | - María López
- Pediatric Surgery Division & Pediatric Airway Unit. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Universidad Complutense de Madrid. Spain
| | - Montserrat Grau
- Research Center, Veterinary Unit. Instituto de Investigación Hospital U. 12 de Octubre (imas12). Avda. de Córdoba s/n, Madrid 28041. Spain
| | - Ma Carmen Luna-Paredes
- Pulmonary Unit, Division of Pediatrics. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Spain
| | - Salomé Albi
- Pulmonary Unit, Division of Pediatrics. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Spain
| | - Marina Alonso-Riaño
- Division of Pathology. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Spain
| | - José L Pablos
- Inflammatory and Autoimmune Diseases Research Group. Instituto de Investigación Hospital U. 12 de Octubre (imas12). Avda. de Córdoba s/n, Madrid 28041. Spain
| | - Juan L Antón-Pacheco
- Pediatric Surgery Division & Pediatric Airway Unit. Hospital Universitario 12 de Octubre. Avda. de Córdoba s/n, Madrid 28041. Universidad Complutense de Madrid. Spain.,Inflammatory and Autoimmune Diseases Research Group. Instituto de Investigación Hospital U . 12 de Octubre (imas12). Avda. de Córdoba s/n, Madrid, 28041, . Spain
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5
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Hysinger EB. Central airway issues in bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:3518-3526. [PMID: 33835725 PMCID: PMC8656371 DOI: 10.1002/ppul.25417] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/10/2021] [Indexed: 11/10/2022]
Abstract
While there is a very large focus on the abnormalities of parenchymal lung development and extensive efforts to minimize alveolar damage with "gentle ventilation" and noninvasive respiratory support for neonates with bronchopulmonary dysplasia (BPD), there is relatively little consideration for the implications of central airway disease in this patient population. There are significant changes in the structure and conformation of the central airway during the last half of gestation, and premature birth disrupts this natural developmental process. The arrest of maturation results in a smaller airway that is more compliant, easier to deform, and more susceptible to damage. Consequently, neonates with BPD are prone to developing central airway pathology, particularly for patients who require intubation and positive pressure ventilation. Central airway disease can be divided into dynamic and fixed airway obstruction and results in increased respiratory morbidity in neonates with chronic lung disease of prematurity.
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Affiliation(s)
- Erik B Hysinger
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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6
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Evaluation of Agreement on Presence and Severity of Tracheobronchomalacia by Dynamic Flexible Bronchoscopy. Ann Am Thorac Soc 2021; 18:1749-1752. [PMID: 34000226 DOI: 10.1513/annalsats.202009-1142rl] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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7
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Kamran A, Baird CW, Jennings RW. Tracheobronchomalacia, Tracheobronchial Compression, and Tracheobronchial Malformations: Diagnostic and Treatment Strategies. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 23:53-61. [PMID: 32354548 DOI: 10.1053/j.pcsu.2020.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 11/11/2022]
Abstract
Tracheobronchomalacia (TBM) is an excessive dynamic narrowing of the airway that is greatest with increased mediastinal pressure such as coughing, Valsalva, and forced expiration. Airway compression and/or cartilage malformation is a fixed or static narrowing of the airway typically caused by great vessel malposition and/or abnormalities and may also contribute to airway narrowing. Although imprecise and misleading, the term TBM is often used to represent both problems, static and dynamic airway narrowing, which only serves to confuse and may mislead the treatment team into ineffective therapies. The consequences of airway narrowing caused by dynamic TBM and/or static compression includes a range of clinical signs and symptoms, depending on the location, extent, and severity of the airway collapse. All patients with mild to severe TBM benefit from medical management to optimize airway clearance of mucus. The milder cases of TBM may become asymptomatic with this therapy, allowing time for the child to grow and the airway to enlarge without the consequences of recurrent infections. In cases of more severe TBM with clinical sequelae, more aggressive management may be warranted. Multiple options for surgical intervention are available. This article discusses the details of clinical presentation, evaluation, diagnosis, and a variety of treatments.
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Affiliation(s)
- Ali Kamran
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Russell W Jennings
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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8
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Wong ZH, Hewitt R, Cross K, Butler C, Yeh YT, Ramaswamy M, Blackburn S, Giuliani S, Muthialu N, De Coppi P. Thoracoscopic aortopexy for symptomatic tracheobronchomalacia. J Pediatr Surg 2020; 55:229-233. [PMID: 31826817 DOI: 10.1016/j.jpedsurg.2019.10.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/26/2019] [Indexed: 11/19/2022]
Abstract
AIM Symptomatic tracheobronchomalacia can be fatal. Successful treatment includes aortopexy. We report outcomes of the thoracoscopic approach in a single centre. METHODS All patients undergoing thoracoscopic aortopexies from 2009 to 2018 were retrospectively reviewed. Data was reported as median (interquartile range). Risk factors for subsequent tracheostomy were analyzed with logistics regression model, p < 0.05 as significant. RESULTS Twenty-one patients with mid to distal tracheomalacia (n = 17) and bronchial involvement (n = 4) were determined on bronchoscopy, tracheobronchogram, or CT thorax. Preoperative patient demographics and comorbidities, e.g., gastro-oesophageal reflux disease, prematurity, and cardiac anomalies were recorded. Indications for thoracoscopic aortopexy were apparent life-threatening event(s) (n = 14), recurrent chest infections (n = 5), and failure to wean invasive ventilation (n = 2). Thoracoscopic aortopexies (n = 20) with conversion to open (n = 1) were performed. Intraoperative bleeding (n = 2) occurred, and chest tube (n = 1) was inserted for monitoring. Intraoperative bronchoscopy (n = 17) confirmed improvement of tracheomalacia. Anesthetic time was 140 (90-160) minutes. Postoperatively, 2 patients had dehiscence of the aorta from the sternum. They underwent redo open aortopexy with posterior tracheopexy, and 1 required subsequent tracheostomy. Another 2 patients required tracheostomies. Potential risk factors for subsequent tracheostomy were investigated, and only the association of tracheobronchomalacia was close to significance (OR 16 (95% CI 0.95-267.03), p = 0.05). Follow up duration was 365 (72-854) days. Symptoms resolution occurred in n = 17 (81%) of patients. CONCLUSION Different modalities were used to delineate the site of tracheobronchomalacia and its etiology. Tracheomalacia with bronchial involvement may be a risk factor for subsequent tracheostomy. LEVEL OF EVIDENCE Level 3 (Case Series).
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Affiliation(s)
- Zeng Hao Wong
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom; Paediatric Surgery, Mount Alvernia Hospital, Singapore
| | - Richard Hewitt
- Tracheal Team, Great Ormond Street Hospital, London, United Kingdom; Department of Otolaryngology, Great Ormond Street Hospital, London, United Kingdom
| | - Kate Cross
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Colin Butler
- Tracheal Team, Great Ormond Street Hospital, London, United Kingdom; Department of Otolaryngology, Great Ormond Street Hospital, London, United Kingdom; Stem Cell and Regenerative Medicine Section, DBC, University College London, Great Ormond Institute of Child Health, London, United Kingdom
| | - Yi-Ting Yeh
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom; Paediatric Surgery, National Yang Ming University, School of Medicine, Taiwan
| | | | - Simon Blackburn
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Stefano Giuliani
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom
| | - Nagarajan Muthialu
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Paolo De Coppi
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital, Paediatric Surgery, London, United Kingdom; Stem Cell and Regenerative Medicine Section, DBC, University College London, Great Ormond Institute of Child Health, London, United Kingdom.
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9
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Thoracoscopic Posterior Tracheopexy Is a Feasible and Effective Treatment for Tracheomalacia. J Laparoendosc Adv Surg Tech A 2019; 29:1228-1231. [DOI: 10.1089/lap.2019.0156] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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10
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Wallis C, Alexopoulou E, Antón-Pacheco JL, Bhatt JM, Bush A, Chang AB, Charatsi AM, Coleman C, Depiazzi J, Douros K, Eber E, Everard M, Kantar A, Masters IB, Midulla F, Nenna R, Roebuck D, Snijders D, Priftis K. ERS statement on tracheomalacia and bronchomalacia in children. Eur Respir J 2019; 54:13993003.00382-2019. [PMID: 31320455 DOI: 10.1183/13993003.00382-2019] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/16/2019] [Indexed: 01/20/2023]
Abstract
Tracheomalacia and tracheobronchomalacia may be primary abnormalities of the large airways or associated with a wide variety of congenital and acquired conditions. The evidence on diagnosis, classification and management is scant. There is no universally accepted classification of severity. Clinical presentation includes early-onset stridor or fixed wheeze, recurrent infections, brassy cough and even near-death attacks, depending on the site and severity of the lesion. Diagnosis is usually made by flexible bronchoscopy in a free-breathing child but may also be shown by other dynamic imaging techniques such as low-contrast volume bronchography, computed tomography or magnetic resonance imaging. Lung function testing can provide supportive evidence but is not diagnostic. Management may be medical or surgical, depending on the nature and severity of the lesions, but the evidence base for any therapy is limited. While medical options that include bronchodilators, anti-muscarinic agents, mucolytics and antibiotics (as well as treatment of comorbidities and associated conditions) are used, there is currently little evidence for benefit. Chest physiotherapy is commonly prescribed, but the evidence base is poor. When symptoms are severe, surgical options include aortopexy or posterior tracheopexy, tracheal resection of short affected segments, internal stents and external airway splinting. If respiratory support is needed, continuous positive airway pressure is the most commonly used modality either via a face mask or tracheostomy. Parents of children with tracheobronchomalacia report diagnostic delays and anxieties about how to manage their child's condition, and want more information. There is a need for more research to establish an evidence base for malacia. This European Respiratory Society statement provides a review of the current literature to inform future study.
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Affiliation(s)
- Colin Wallis
- Respiratory Medicine Unit, Great Ormond Street Hospital for Children, London, UK
| | - Efthymia Alexopoulou
- 2nd Radiology Dept, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Juan L Antón-Pacheco
- Pediatric Airway Unit and Pediatric Surgery Division, Universidad Complutense de Madrid, Madrid, Spain
| | - Jayesh M Bhatt
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Andrew Bush
- Imperial College London and Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anne B Chang
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia.,Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
| | | | | | - Julie Depiazzi
- Physiotherapy Dept, Perth Children's Hospital, Perth, Australia
| | - Konstantinos Douros
- Allergology and Pulmonology Unit, 3rd Paediatric Dept, National and Kapodistrian University of Athens, Athens, Greece
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Dept of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Mark Everard
- Division of Paediatrics, University of Western Australia, Perth Children's Hospital, Perth, Australia
| | - Ahmed Kantar
- Pediatric Asthma and Cough Centre, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
| | - Ian B Masters
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia.,Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Fabio Midulla
- Dept of Paediatrics, "Sapienza" University of Rome, Rome, Italy
| | - Raffaella Nenna
- Dept of Paediatrics, "Sapienza" University of Rome, Rome, Italy.,Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Derek Roebuck
- Interventional Radiology Dept, Great Ormond Street Hospital, London, UK
| | - Deborah Snijders
- Dipartimento Salute della Donna e del Bambino, Università degli Studi di Padova, Padova, Italy
| | - Kostas Priftis
- Allergology and Pulmonology Unit, 3rd Paediatric Dept, National and Kapodistrian University of Athens, Athens, Greece
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11
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Bates AJ, Higano NS, Hysinger EB, Fleck RJ, Hahn AD, Fain SB, Kingma PS, Woods JC. Quantitative Assessment of Regional Dynamic Airway Collapse in Neonates via Retrospectively Respiratory-Gated 1 H Ultrashort Echo Time MRI. J Magn Reson Imaging 2019; 49:659-667. [PMID: 30252988 PMCID: PMC6375762 DOI: 10.1002/jmri.26296] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/27/2018] [Accepted: 07/27/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Neonatal dynamic tracheal collapse (tracheomalacia, TM) is a common and serious comorbidity in infants, particularly those with chronic lung disease of prematurity (bronchopulmonary dysplasia, BPD) or congenital airway or lung-related conditions such as congenital diaphragmatic hernia (CDH), but the underlying pathology, impact on clinical outcomes, and response to therapy are not well understood. There is a pressing clinical need for an accurate, objective, and safe assessment of neonatal TM. PURPOSE To use retrospectively respiratory-gated ultrashort echo-time (UTE) MRI to noninvasively analyze moving tracheal anatomy for regional, quantitative evaluation of dynamic airway collapse in quiet-breathing, nonsedated neonates. STUDY TYPE Prospective. POPULATION/SUBJECTS Twenty-seven neonatal subjects with varying respiratory morbidities (control, BPD, CDH, abnormal polysomnogram). FIELD STRENGTH/SEQUENCE High-resolution 3D radial UTE MRI (0.7 mm isotropic) on 1.5T scanner sited in the neonatal intensive care unit. ASSESSMENT Images were retrospectively respiratory-gated using the motion-modulated time-course of the k-space center. Tracheal surfaces were generated from segmentations of end-expiration/inspiration images and analyzed geometrically along the tracheal length to calculate percent-change in luminal cross-sectional area (A % ) and ratio of minor-to-major diameters at end-expiration (r D,exp ). Geometric results were compared to clinically available bronchoscopic findings (n = 14). STATISTICAL TESTS Two-sample t-test. RESULTS Maximum A % significantly identified subjects with/without a bronchoscopic TM diagnosis (with: 46.9 ± 10.0%; without: 27.0 ± 5.8%; P < 0.001), as did minimum r D,exp (with: 0.346 ± 0.146; without: 0.671 ± 0.218; P = 0.008). Subjects with severe BPD exhibited a far larger range of minimum r D,exp than subjects with mild/moderate BPD or controls (0.631 ± 0.222, 0.782 ± 0.075, and 0.776 ± 0.030, respectively), while minimum r D,exp was reduced in CDH subjects (0.331 ± 0.171) compared with controls (P < 0.001). DATA CONCLUSION Respiratory-gated UTE MRI can quantitatively and safely evaluate neonatal dynamic tracheal collapse, as validated with the clinical standard of bronchoscopy, without requiring invasive procedures, anesthesia, or ionizing radiation. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2019;49:659-667.
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Affiliation(s)
- Alister J Bates
- Upper Airway Center, Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Nara S Higano
- Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Erik B Hysinger
- Upper Airway Center, Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Robert J Fleck
- Upper Airway Center, Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Andrew D Hahn
- Department of Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Sean B Fain
- Department of Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, USA
- Department of Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Paul S Kingma
- Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Jason C Woods
- Upper Airway Center, Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Center for Pulmonary Imaging Research, Division of Pulmonary Medicine and Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Departments of Radiology and Physics, University of Cincinnati, Cincinnati, Ohio, USA
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12
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Choi S, Lawlor C, Rahbar R, Jennings R. Diagnosis, Classification, and Management of Pediatric Tracheobronchomalacia. JAMA Otolaryngol Head Neck Surg 2019; 145:265-275. [DOI: 10.1001/jamaoto.2018.3276] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sukgi Choi
- Department of Otolaryngology & Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Claire Lawlor
- Department of Otolaryngology & Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Reza Rahbar
- Department of Otolaryngology & Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
| | - Russell Jennings
- Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts
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13
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Kamran A, Jennings RW. Tracheomalacia and Tracheobronchomalacia in Pediatrics: An Overview of Evaluation, Medical Management, and Surgical Treatment. Front Pediatr 2019; 7:512. [PMID: 31921725 PMCID: PMC6922019 DOI: 10.3389/fped.2019.00512] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/26/2019] [Indexed: 01/13/2023] Open
Abstract
Tracheobronchomalacia (TBM) refers to airway collapse due to typically excessive posterior membrane intrusion and often associated with anterior cartilage compression. TBM occurs either in isolation or in association with other congenital or acquired conditions. Patients with TM typically present non-specific respiratory symptoms, ranging from noisy breathing with a typical barking cough to respiratory distress episodes to acute life-threatening events and recurrent and/or prolonged respiratory infections. There are no definitive standardized guidelines for the evaluation, diagnosis, and treatment of TBM; therefore, patients may be initially misdiagnosed and incorrectly treated. Although milder cases of TBM may become asymptomatic as the diameter of the airway enlarges with the child, in cases of severe TBM, more aggressive management is warranted. This article is an overview of the clinical presentation, evaluation, diagnosis, medical management, and surgical treatment options in pediatric tracheomalacia.
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Affiliation(s)
- Ali Kamran
- Department of General Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
| | - Russell W Jennings
- Department of General Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, United States
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Gherasim A, Dao A, Bernstein JA. Confounders of severe asthma: diagnoses to consider when asthma symptoms persist despite optimal therapy. World Allergy Organ J 2018; 11:29. [PMID: 30459928 PMCID: PMC6234696 DOI: 10.1186/s40413-018-0207-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 09/18/2018] [Indexed: 12/30/2022] Open
Abstract
Asthma can often be challenging to diagnose especially when patients present with atypical symptoms. Therefore, it is important to have a broad differential diagnosis for asthma to ensure that other conditions are not missed. Clinicians must maintain a high index of suspicion for asthma mimickers, especially when patients fail to respond to conventional therapy. The purpose of this review is to briefly review some of the more common causes of asthma mimickers that clinicians should consider when the diagnosis of asthma is unclear.
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Affiliation(s)
- Alina Gherasim
- Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Ahn Dao
- University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Jonathan A Bernstein
- University of Cincinnati College of Medicine, Cincinnati, OH USA
- Department of Internal Medicine, Division of Immunology Rheumatology and Allergy, University of Cincinnati, 231 Albert Sabin Way ML#563, Cincinnati, OH 45267-0563 USA
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Wallis C, McLaren CA. Tracheobronchial stenting for airway malacia. Paediatr Respir Rev 2018; 27:48-59. [PMID: 29174374 DOI: 10.1016/j.prrv.2017.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 11/28/2022]
Abstract
Tracheobronchomalacia is a rare but clinically troublesome condition in paediatrics. The softening of the major airways - which can include some or all of the tracheobronchial tree can lead to symptoms ranging from the minor (harsh barking cough, recurrent chest infections) to severe respiratory difficulties including prolonged ventilator support and 'near death attacks'. The causes are broadly divided into intrinsic softening of the airway wall which is considered a primary defect (e.g. syndromes; post tracheo-oesophageal fistula repair; extreme prematurity) or secondary malacia due to external compression from vascular structures or cardiac components. These secondary changes can persist even when the external compression is relieved, for example, following the repair of a pulmonary artery sling or double aortic arch. For children with severe clinical symptoms attributed to malacia, consideration is given to possible surgical remedies such as an aortopexy for short limited areas of malacia, or long term positive pressure support with CPAP either by non invasive or tracheostomy interface. More recently the role of stenting in children is receiving attention, especially with the development of newer techniques such as bioabsorbable stents which buy time for a natural history of improvement in the malacia to occur. This paper reviews the stents available and discusses the pros and cons of stenting in paediatric airway malacia.
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Affiliation(s)
- Colin Wallis
- Department of Respiratory Paediatrics, Great Ormond Street Hospital for Children, London, UK.
| | - Clare A McLaren
- Department of Radiology, Great Ormond Street Hospital for Children, London, UK
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Dikina AD, Alt DS, Herberg S, McMillan A, Strobel HA, Zheng Z, Cao M, Lai BP, Jeon O, Petsinger VI, Cotton CU, Rolle MW, Alsberg E. A Modular Strategy to Engineer Complex Tissues and Organs. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2018; 5:1700402. [PMID: 29876200 PMCID: PMC5978945 DOI: 10.1002/advs.201700402] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 08/28/2017] [Indexed: 05/25/2023]
Abstract
Currently, there are no synthetic or biologic materials suitable for long-term treatment of large tracheal defects. A successful tracheal replacement must (1) have radial rigidity to prevent airway collapse during respiration, (2) contain an immunoprotective respiratory epithelium, and (3) integrate with the host vasculature to support epithelium viability. Herein, biopolymer microspheres are used to deliver chondrogenic growth factors to human mesenchymal stem cells (hMSCs) seeded in a custom mold that self-assemble into cartilage rings, which can be fused into tubes. These rings and tubes can be fabricated with tunable wall thicknesses and lumen diameters with promising mechanical properties for airway collapse prevention. Epithelialized cartilage is developed by establishing a spatially defined composite tissue composed of human epithelial cells on the surface of an hMSC-derived cartilage sheet. Prevascular rings comprised of human umbilical vein endothelial cells and hMSCs are fused with cartilage rings to form prevascular-cartilage composite tubes, which are then coated with human epithelial cells, forming a tri-tissue construct. When prevascular- cartilage tubes are implanted subcutaneously in mice, the prevascular structures anastomose with host vasculature, demonstrated by their ability to be perfused. This microparticle-cell self-assembly strategy is promising for engineering complex tissues such as a multi-tissue composite trachea.
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Affiliation(s)
- Anna D. Dikina
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Daniel S. Alt
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Samuel Herberg
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Alexandra McMillan
- Department of PathologyCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Hannah A. Strobel
- Department of Biomedical EngineeringWorcester Polytechnic Institute100 Institute RoadWorcesterMA01609USA
| | - Zijie Zheng
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Meng Cao
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Bradley P. Lai
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Oju Jeon
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Victoria Ivy Petsinger
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Calvin U. Cotton
- Department of PediatricsDepartment of Physiology and BiophysicsCase Western Reserve University10900 Euclid AveClevelandOH44106USA
| | - Marsha W. Rolle
- Department of Biomedical EngineeringWorcester Polytechnic Institute100 Institute RoadWorcesterMA01609USA
| | - Eben Alsberg
- Department of Biomedical EngineeringCase Western Reserve University10900 Euclid AveClevelandOH44106USA
- Department of Orthopaedic SurgeryNational Center for Regenerative MedicineCase Western Reserve University10900 Euclid AveClevelandOH44106USA
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Abstract
RATIONALE Tracheobronchomalacia is a common comorbidity in neonates with bronchopulmonary dysplasia. However, the effect of tracheobronchomalacia on the clinical course of bronchopulmonary dysplasia is not well-understood. OBJECTIVE We sought to assess the impact of tracheobronchomalacia on outcomes in neonates with bronchopulmonary dysplasia in a large, multi-center cohort. METHODS We preformed a cohort study of 974 neonates with bronchopulmonary dysplasia admitted to 27 neonatal intensive care units participating in the Children's Hospital Neonatal Database who had undergone bronchoscopy. In hospital morbidity for neonates with bronchopulmonary dysplasia and tracheobronchomalacia (N=353, 36.2%) was compared to those without tracheobronchomalacia (N=621, 63.8%) using mixed-effects multivariate regression. RESULTS Neonates with tracheobronchomalacia and bronchopulmonary dysplasia had more comorbidities, such as gastroesophageal reflux (OR=1.65, 95%CI 1.23- 2.29, P=0.001) and pneumonia (OR=1.68, 95%CI 1.21-2.33, P=0.002) and more commonly required surgeries such as tracheostomy (OR=1.55, 95%CI 1.15-2.11, P=0.005) and gastrostomy (OR=1.38, 95%CI 1.03-1.85, P=0.03) compared with those without tracheobronchomalacia. Neonates with tracheobronchomalacia were hospitalitized (118 ± 93 vs 105 ± 83 days, P=0.02) and ventilated (83.1 ± 91.1 vs 67.2 ± 71.9 days, P=0.003) longer than those without tracheobronchomalacia. Upon discharge, neonates with tracheobronchomalacia and BPD were more likely to be mechanically ventilated (OR=1.37, 95CI 1.01-1.87 P=0.045) and possibly less likely to receive oral nutrition (OR=0.69, 95%CI 0.47-1.01, P=0.058). CONCLUSIONS Tracheobronchomalacia is common in neonates with bronchopulmonary dysplasia who undergo bronchoscopy and is associated with longer and more complicated hospitalizations.
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Abstract
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.
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Affiliation(s)
- Abhishek Biswas
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States.
| | - Michael A Jantz
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
| | - P S Sriram
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
| | - Hiren J Mehta
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
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Teflon Injection into the Trachea Causes Predictable Fibroblastic Response and Collagen Deposition: A Pilot Study. J Bronchology Interv Pulmonol 2017; 23:283-287. [PMID: 27764007 DOI: 10.1097/lbr.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Expiratory central airway collapse is an increasingly recognized abnormality of the central airways and may be present in as many as 22% of patients evaluated for chronic obstructive pulmonary disease and/or asthma. Many current treatment options require invasive procedures that have been shown to cause significant morbidity and mortality. To test the hypothesis that Teflon injection will induce sufficient fibroblast proliferation and collagen deposition, we evaluated the time course on the effect of Teflon injection in the posterior membranous trachea on the histopathology of the tracheobronchial tree. METHODS Six Yucatan Pigs were assigned to undergo general anesthesia and injection of 0.3 to 0.5 mL of sterile Teflon paste in 50% glycerin into the posterior membranous tracheal wall. A control pig received an equivalent volume of glycerin. Animals were euthanized in predefined intervals and tracheas were excised and examined under light microscopy for identifying fibroblast proliferation and collagen deposition. RESULTS Compared with the control pig, the Teflon injection site showed tissue reaction of fibrohistiocytic proliferation and subsequent collagen deposition in all animals. Furthermore, the increased fibroblast proliferation and collagen deposition were time dependent (P<0.01). CONCLUSION This pilot study demonstrates histopathologic changes in the trachea after Teflon injection, comprised of increased fibroblast activity and collagen deposition that could be of potential use in creating greater airway rigidity in patients with sever diffuse excessive dynamic airway collapse.
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Bryant R. External tracheal stenting for pediatric airway obstruction: A word of caution. J Thorac Cardiovasc Surg 2017; 153:1178-1179. [PMID: 28237064 DOI: 10.1016/j.jtcvs.2017.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/10/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Roosevelt Bryant
- Division of Cardiovascular Surgery, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Ando M, Nagase Y, Hasegawa H, Takahashi Y. External stenting: A reliable technique to relieve airway obstruction in small children. J Thorac Cardiovasc Surg 2017; 153:1167-1177. [PMID: 28242014 DOI: 10.1016/j.jtcvs.2016.12.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 12/05/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Airway obstruction in children may be caused by conditions such as vascular compression and congenital tracheobronchomalacia. Obstructive pulmonary vascular disease may be a detrimental sequel for patients with congenital heart disease. We evaluate our own original external stenting technique as a treatment option for these patients. METHODS Ninety-eight patients underwent external stenting (1997-2015). Cardiovascular anomalies were noted in 82 (83.7%). Nine patients had hypoplastic left heart syndrome and 6 had other types of single-ventricular hearts. RESULTS The median age at the first operation was 7.2 months (range, 1.0-77.1 months). The mechanisms were tracheobronchomalacia with (n = 46) or without (n = 52) vascular compression. Patients underwent 127 external stentings for 139 obstruction sites (62 trachea, 55 left bronchus, and 22 right bronchus). The stent sizes varied from 12 to 16 mm. There were 14 (8 in the hospital and 6 after discharge) mortality cases. Nine required reoperation for restenosis and 3 required stent removal for infection. The actuarial freedom from mortality and any kind of reoperation was 74.7% ± 4.6% after 2.8 years. The negative pressure threshold to induce airway collapse for congenital malacia (n = 58) improved from -15.9 to -116.0 cmH2O. A follow-up computed tomography scan (>2.0 years interval from the operation; n = 23) showed the mean diameter of the stented segment at 88.5% ± 13.7% (bronchus) and 94.5% ± 8.2% (trachea) of the reference. CONCLUSIONS External stenting is a reliable method to relieve airway compression for small children, allowing an age-proportional growth of the airway.
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Affiliation(s)
| | | | - Hisaya Hasegawa
- Tokyo Women's Medical University Medical Center East, Tokyo, Japan
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Abstract
Tracheomalacia (TM) is defined as an increased collapsibility of the trachea due to structural anomalies of the tracheal cartilage and/or posterior membrane. Tracheomalacia has a wide range of etiologies but is most commonly present in children born with esophageal atresia and tracheal esophageal fistula. Clinical symptoms can range from minor expiratory stridor with typical barking cough to severe respiratory distress episodes to acute life-threatening events (ALTE). Although the majority of children have mild-to-moderate symptoms and will not need surgical intervention, some will need life-changing surgical treatment. This article examines the published pediatric literature on TM, discusses the details of clinical presentation, evaluation, diagnosis, and a variety of treatments.
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Affiliation(s)
- Jose Carlos Fraga
- Department of Surgery, Pediatric Surgeon at Hospitals de Clinicas, Moinhos de Vento and Materno-Infantil Presidente Vargas, Federal University of Rio Grande do Sul, Rua Ramiro Barcelos 2350, Sala 600-Porto Alegre, CEP90035-903, Porto Alegre, RS, Brazil.
| | - Russell W Jennings
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, USA, MA
| | - Peter C W Kim
- Department of General and Thoracic Surgery, Children's Medical Center, Washington University, Washington, DC
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Abstract
Intrathoracic tracheomalacia is characterized by increased compliance of the central airway within the thorax. This leads to excessive dynamic collapse during exhalation or periods of increased intrathoracic pressure such as crying. Extrathoracic tracheomalacia involves dynamic collapse of the airway between the glottis and sternal notch that occurs during inhalation rather than exhalation. The tone of the posterior membrane of the trachea increases throughout development and childhood, as does the rigidity of the tracheal cartilage. Abnormalities of airway maturation result in congenital tracheomalacia. Acquired tracheomalacia occurs in the normally developed trachea due to trauma, external compression, or airway inflammation. Although tracheomalacia can be suspected by history, physical examination, and supportive radiographic findings, flexible fiberoptic bronchoscopy remains the "gold standard" for diagnosis. Current treatment strategies involve pharmacotherapy with cholinergic agents, positive pressure ventilation, and surgical repair.
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Affiliation(s)
- Erik B Hysinger
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
| | - Howard B Panitch
- Perelman School of Medicine at the University of Pennsylvania, Attending Physician, Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
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Dutau H, Musani AI, Plojoux J, Laroumagne S, Astoul P. The use of self-expandable metallic stents in the airways in the adult population. Expert Rev Respir Med 2014; 8:179-90. [PMID: 24450436 DOI: 10.1586/17476348.2014.880055] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The airway stents restore patency in the face of luminal compromise from intrinsic and/or extrinsic pathologies. Luminal compromise beyond 50% often leads to debilitating symptoms such as dyspnea. Silicone stents remain the most commonly placed stents worldwide and have been the "gold standard" for the treatment of benign and malignant airway stenoses over the past 20 years. Nevertheless, silicone stents are not the ideal stents in all situations. Metallic stents can serve better in some selected conditions. Unlike silicone stents, there are large and increasing varieties of metallic stents available on the market. The lack of prospective or comparative studies between various types of metallic stents makes the choice difficult and expert-opinion based. International guidelines are sorely lacking in this area.
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Affiliation(s)
- Herve Dutau
- North University Hospital, Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Marseille, 13015 France
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What's in a name? Expiratory tracheal narrowing in adults explained. Clin Radiol 2013; 68:1268-75. [DOI: 10.1016/j.crad.2013.06.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 06/21/2013] [Accepted: 06/26/2013] [Indexed: 10/26/2022]
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Refractory asthma treatment is complicated by tracheobronchomalacia: case reports and review of the literature. Case Rep Med 2013; 2013:735058. [PMID: 23762075 PMCID: PMC3666332 DOI: 10.1155/2013/735058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 04/22/2013] [Indexed: 12/26/2022] Open
Abstract
Tracheobronchomalacia (TBM) is defined as the condition where the airway lumen narrows more than 50 percent. The acquired TBM usually occurs in adults; however, the prevalence of TBM in asthma is unknown. We report two cases of severe asthma in elderly patients that could not be controlled with higher medication use. Case 1 was a 70-year-old woman with sever persistent asthma for 10 years, presented with uncontrolled symptoms for 4 months. A CT of the chest showed collapse of the trachea at the posterior wall. Case 2 involved a 72-year-old woman with partly controlled asthma presenting with uncontrolled symptoms for 3 months. A CT of the chest showed normal distal tracheal anteroposterior diameter. However, bronchoscopy showed bronchomalacia at the right and left bronchus of the lower lungs. Patients who have severe asthma, despite adequate treatment with medication, should be further investigated to exclude other diseases that have clinical features similar to asthma such as tracheobronchomalacia, particularly in the elderly.
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Bottero E, Bellino C, De Lorenzi D, Ruggiero P, Tarducci A, D'Angelo A, Gianella P. Clinical Evaluation and Endoscopic Classification of Bronchomalacia in Dogs. J Vet Intern Med 2013; 27:840-6. [DOI: 10.1111/jvim.12096] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 02/11/2013] [Accepted: 03/14/2013] [Indexed: 12/01/2022] Open
Affiliation(s)
- E. Bottero
- Poliambulatorio Veterinario Argentina; Imperia Italy
| | - C. Bellino
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
| | - D. De Lorenzi
- Veterinary Hospital “I Portoni Rossi”; Bologna Italy
| | - P. Ruggiero
- Centro Veterinario Specialistico; Roma Italy
| | - A. Tarducci
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
| | - A. D'Angelo
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
| | - P. Gianella
- Department of Veterinary Sciences; University of Turin; Grugliasco Italy
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Dutau H, Maldonado F, Laroumagne S, Astoul P. Silicone stents, the rigid bronchoscope, and the standard of care in central airway stenosis. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13665-011-0003-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lee EY, Tracy DA, Bastos MD, Casey AM, Zurakowski D, Boiselle PM. Expiratory Volumetric MDCT Evaluation of Air Trapping in Pediatric Patients With and Without Tracheomalacia. AJR Am J Roentgenol 2010; 194:1210-1215. [DOI: 10.2214/ajr.09.3259] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Edward Y. Lee
- Department of Radiology and Department of Medicine, Pulmonary Division, Children's Hospital Boston and Harvard Medical School, 300 Longwood Ave., Boston, MA 02115
| | - Donald A. Tracy
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Maria d'Almeida Bastos
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Alicia M. Casey
- Department of Medicine, Pulmonary Division, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - David Zurakowski
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Phillip M. Boiselle
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Lee EY, Boiselle PM. Tracheobronchomalacia in infants and children: multidetector CT evaluation. Radiology 2009; 252:7-22. [PMID: 19561247 DOI: 10.1148/radiol.2513081280] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Tracheobronchomalacia (TBM) is the most common congenital central airway anomaly, but it frequently goes unrecognized or is misdiagnosed as other respiratory conditions such as asthma. Recent advances in multidetector computed tomography (CT) have enhanced the ability to noninvasively diagnose TBM with the potential to reduce the morbidity and mortality associated with this condition. Precise indications are evolving but may include symptomatic pediatric patients with known risk factors for TBM and patients with otherwise unexplained impaired exercise tolerance; recurrent lower airways infection; and therapy-resistant, irreversible, and/or atypical asthma. With multidetector CT, radiologists can now perform objective and quantitative assessment of TBM with accuracy similar to that of bronchoscopy, the reference standard for diagnosing this condition. Multidetector CT enables a comprehensive evaluation of pediatric patients suspected of having TBM by facilitating accurate diagnosis, determining the extent and degree of disease, identifying predisposing conditions, and providing objective pre- and postoperative assessments. In this article, the authors present a step-by-step primer of multidetector CT imaging for evaluating infants and children with suspected TBM, including clinical indications, patient preparation, multidetector CT techniques and protocols, two- and three-dimensional processing of multidetector CT data, and image interpretation. The major aim of this article is to facilitate the reader's ability to successfully employ multidetector CT imaging protocols for evaluation of TBM in infants and children in daily clinical practice.
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Affiliation(s)
- Edward Y Lee
- Department of Radiology and Department of Medicine, Pulmonary Division, Children's Hospital Boston and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA.
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Emery JL, Nanayakkara CF, Wailoo MP. Tracheomalacia-Lethal Factor in a 17-month-Old Child. ACTA ACUST UNITED AC 2009; 2:259-65. [PMID: 6542654 DOI: 10.3109/15513818409022259] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A case is reported of a child who died at age 17 months after having repeated respiratory incidents, probably related to mild infections. After a fatal respiratory episode, tracheomalacia was detected at necropsy. No other abnormalities were found. This condition, unless suspected clinically, could easily be overlooked at necropsy.
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Masters IB, Zimmerman PV, Pandeya N, Petsky HL, Wilson SB, Chang AB. Quantified Tracheobronchomalacia Disorders and Their Clinical Profiles in Children. Chest 2008; 133:461-7. [DOI: 10.1378/chest.07-2283] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Johnson JN, Hartman TK, Krych EH, Seferian EG, Ouellette Y. Tracheomalacia in siblings with otopalatodigital syndrome. Am J Med Genet A 2008; 146A:1347-9. [DOI: 10.1002/ajmg.a.32263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Tracheobronchomalacia and excessive dynamic airway collapse are two separate forms of dynamic central airway obstruction that may or may not coexist. These entities are increasingly recognized as asthma and COPD imitators. The understanding of these disease processes, however, has been compromised over the years because of uncertainties regarding their definitions, pathogenesis and aetiology. To date, there is no standardized classification, diagnosis or management algorithm. In this article we comprehensively review the aetiology, morphopathology, physiology, diagnosis and treatment of these entities.
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Affiliation(s)
- Septimiu D Murgu
- Pulmonary and Critical Care Medicine, Department of Medicine, University of California School of Medicine, Irvine, CA, USA
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Abstract
PURPOSE Aortopexy is the accepted operative treatment for severe and localized tracheomalacia (TM). The standard surgical approach involves a left anterior thoracotomy, often under bronchoscopic control. We report the results of aortopexy in 28 children with severe and localized TM; 12 had a left lateral muscle-sparing approach and one had a thoracoscopic aortopexy. METHODS Retrospective review of patient notes was performed to note the indications, investigation findings, and postoperative course after aortopexy. RESULTS The median age at aortopexy was 5 months. The indications included acute life-threatening events in 22, failure to extubate in 5, and recurrent pneumonia in 1. Fifteen had associated esophageal atresia and 13 had primary TM. Symptoms of TM were abolished in 26 of the 28 patients after aortopexy. CONCLUSIONS Aortopexy is a safe and reliable procedure to treat localized intrathoracic TM presenting with acute life-threatening events. It is important to exclude associated problems such as vascular rings and to ensure that the tracheomalacic portion is segmental and does not significantly involve the main bronchi. The lateral muscle-sparing thoracotomy provides good access and is more cosmetic than the standard anterior approach. We would attempt the thoracoscopic approach in older infants and children.
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Affiliation(s)
- Sumit Dave
- Department of Paediatric Surgery, Sydney Children's Hospital, Randwick NSW 2031, Australia.
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Ghanei M, Akbari Moqadam F, Mohammad MM, Aslani J. Tracheobronchomalacia and Air Trapping after Mustard Gas Exposure. Am J Respir Crit Care Med 2006; 173:304-9. [PMID: 16254272 DOI: 10.1164/rccm.200502-247oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
RATIONALE Mustard gas primarily affects the eyes, skin, and particularly the respiratory tract. Tracheobronchomalacia (TBM) and air trapping are often observed in high-resolution computerized tomography (HRCT) scans of the chest of mustard gas-exposed patients. OBJECTIVES To examine the frequency and severity of TBM in a group of Iranian wartime mustard gas-exposed victims, and to investigate the correlation between TBM and air trapping in these cases. MATERIALS AND METHODS Chest HRCT films obtained from 300 randomly selected subjects who had been exposed to mustard gas 15.5 yr previously were reviewed to determine the existence of TBM and air trapping. The HRCT films of a healthy control group were also analyzed for comparison. RESULTS Out of 300 reviewed cases, 13 had TBM. From these 13 TBM cases, 11 (85%) showed air trapping with mean score of 5.5. In the control group, 5 (25%) of 20 subjects showed air trapping, with mean score of 0.6. The total air trapping was significantly higher in the TBM group (p < 0.001). There was an association between the severity of tracheomalacia and air trapping in the TBM group (p = 0.01, r = 0.69), but no association was observed between severity of bronchomalacia and air trapping. CONCLUSION The results show that air trapping and TBM are correlated, both as long-term sequelae in mustard gas-exposed cases. Because air trapping is highly suggestive of bronchiolitis obliterans, we conclude that both bronchiolitis obliterans and TBM are caused by a single underlying process affecting small and large airways, respectively, in this group of patients.
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Affiliation(s)
- Mostafa Ghanei
- Research Center of Chemical Injuries, Baqiyatallah Medical Science University, Mollasadra Street, Tehran, 14359151371, Iran.
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Abstract
Tracheomalacia (TM) is abnormal flaccidity of the trachea caused by inadequate cartilaginous support by the C-shaped tracheal rings. This defect generally results in various degrees of dynamic narrowing of the airway lumen. TM usually presents with expiratory stridor, wheeze, and respiratory obstruction. TM is usually associated with tracheoesophageal fistula and esophageal atresia or with other thoracic lesions of vascular rings and tumors. We report a well-documented case of a 20-month-old boy who presented to our institution with a severe history of obstructive sleep apnea and adenotonsillar hypertrophy. On direct laryngoscopy/bronchoscopy, severe TM was noted. Tonsillectomy and adenoidectomy was performed, and by the 37th postoperative day, the TM had completely resolved. We review the literature, discuss the differential diagnosis and clinical evaluation, and propose a new pathophysiological mechanism by which obstructive sleep apnea causes TM.
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Carden KA, Boiselle PM, Waltz DA, Ernst A. Tracheomalacia and Tracheobronchomalacia in Children and Adults. Chest 2005; 127:984-1005. [PMID: 15764786 DOI: 10.1378/chest.127.3.984] [Citation(s) in RCA: 423] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Tracheomalacia and tracheobronchomalacia are disorders that are encountered in both pediatric and adult medicine. Despite increasing recognition of these disease processes, there remains some uncertainty regarding their identification, causes, and treatment. This article is intended to be a comprehensive review of both the adult and pediatric forms of the diseases, and includes sections on the historical aspects of the disorders, and their classification, associated conditions, histopathology, and natural history. We also review the various modalities that are used for diagnosis as well as the state of the art of treatment, including airway stent placement and surgical intervention.
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Affiliation(s)
- Kelly A Carden
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02446, USA
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Okazaki J, Isono S, Hasegawa H, Sakai M, Nagase Y, Nishino T. Quantitative Assessment of Tracheal Collapsibility in Infants with Tracheomalacia. Am J Respir Crit Care Med 2004; 170:780-5. [PMID: 15242842 DOI: 10.1164/rccm.200312-1691oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Infantile tracheomalacia is a potentially life-threatening disease requiring prolonged artificial respiratory support. Diagnosis and management of this disease may be further improved by establishing a suitable objective and quantitative assessment protocol for tracheal collapsibility. It is our hypothesis that tracheal collapsibility can be represented by the relationship between intraluminal pressure and the cross-sectional area of the trachea. To test this hypothesis, static pressure/area relationships of the trachea were obtained from anesthetized and paralyzed infants, who were diagnosed as having tracheomalacia by endoscopic observation. These relationships were fitted on a linear regression model, followed by calculation of the estimated closing pressure. The tracheal closing pressure ranged from -8 to -27 cm H(2)O, suggesting easy collapsibility of the trachea during crying or coughing and noncollapsibility during the spontaneous respiratory cycle, which coincided with the infants' symptoms. It is our conclusion that tracheal collapsibility of infants with tracheomalacia can be quantitatively assessed by the static pressure/area relationship of the trachea obtained under general anesthesia and paralysis.
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Affiliation(s)
- Junko Okazaki
- Department of Anesthesiology (B1), Graduate School of Medicine, Chiba University, 1-8-1 Inohana-cho, Chuo-ku, Chiba 260-8670, Japan
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Hofhuis W, van der Wiel EC, Tiddens HAWM, Brinkhorst G, Holland WPJ, de Jongste JC, Merkus PJFM. Bronchodilation in infants with malacia or recurrent wheeze. Arch Dis Child 2003; 88:246-9. [PMID: 12598393 PMCID: PMC1719464 DOI: 10.1136/adc.88.3.246] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Controversy remains regarding the effectiveness of bronchodilators in wheezy infants. AIMS To assess the effect of inhaled beta(2) agonists on lung function in infants with malacia or recurrent wheeze, and to determine whether a negative effect of beta(2) agonists on forced expiratory flow (V'(maxFRC)) is more pronounced in infants with airway malacia, compared to infants with wheeze. METHODS We retrospectively analysed lung function data of 27 infants: eight with malacia, 19 with recurrent wheeze. Mean (SD) age was 51 (18) weeks. Mean V'(maxFRC) (in Z score) was assessed before and after inhalation of beta(2) agonists. RESULTS Baseline V'(maxFRC) was below reference values for both groups. Following inhalation of beta(2) agonists the mean (95% CI) change in mean V'(maxFRC) in Z scores was -0.10 (-0.26 to 0.05) and -0.33 (-0.55 to -0.11) for the malacia and wheeze group, respectively. CONCLUSIONS In infants with wheeze, inhaled beta(2) agonists caused a significant reduction in mean V'(maxFRC). Infants with malacia were not more likely to worsen after beta(2) agonists than were infants with recurrent wheeze.
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Affiliation(s)
- W Hofhuis
- Department of Paediatrics, Division of Respiratory Medicine, Erasmus University Medical Centre, Sophia Children's Hospital, Rotterdam, Netherlands.
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Prótesis traqueobronquiales endoluminales: alternativa terapéutica en la traqueobroncomalacia grave. An Pediatr (Barc) 2002. [DOI: 10.1016/s1695-4033(02)77796-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Asai T, Shingu K. Airway obstruction in a child with asymptomatic tracheobronchomalacia. Can J Anaesth 2001; 48:684-7. [PMID: 11495877 DOI: 10.1007/bf03016204] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To report a case of airway obstruction with hypoxia during emergence from anesthesia due to unexpected tracheobronchomalacia in a child. CLINICAL FEATURES In a previously healthy 22-month-old boy with no symptoms or signs of respiratory disease, general anesthesia was induced by inhalation of increasing concentrations of sevoflurane (up to 5%) in oxygen and a laryngeal mask was inserted. Partial airway obstruction persisted during surgery, but obstruction was relieved by positive-pressure ventilation. During emergence from anesthesia, airway obstruction with hypoxia occurred, necessitating tracheal intubation. Emission of carbon dioxide as well as of sevoflurane was reduced and emergence from anesthesia markedly delayed. Fibreoptic tracheoscopy showed marked collapse of the tracheobronchi during expiration, and a diagnosis of tracheobronchomalacia was made. No respiratory complications occurred postoperatively. CONCLUSION Asymptomatic tracheomalacia should also be suspected in case of airway obstruction during anesthesia in young children.
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Affiliation(s)
- T Asai
- Department of Anesthesiology, Kansai Medical University, Osaka, Japan.
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Le BT, Eyre JM, Holmgren EP, Dierks EJ. A tracheostomy complication resulting from acquired tracheomalacia: case report. THE JOURNAL OF TRAUMA 2001; 50:120-3. [PMID: 11253758 DOI: 10.1097/00005373-200101000-00022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- B T Le
- Department of Oral and Maxillofacial Surgery, LAC-USC Medical Center, Los Angeles, CA, USA
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Abstract
A child with a long standing history of cyanotic breath holding attacks presented with acute respiratory distress. Subsequent investigation established that her clinical condition was caused by tracheomalacia. We hypothesise that tracheomalacia might be an under recognised contributor to cyanotic breath holding attacks, the pathogenesis of which is poorly understood.
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Affiliation(s)
- H Griffiths
- Department of Otorhinolaryngology, University Hospital of Wales, Cardiff, UK.
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