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December 27, 2018

Diagnosis, Classification, and Management of Pediatric Tracheobronchomalacia: A Review

Author Affiliations
  • 1Department of Otolaryngology & Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
  • 2Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. Published online December 27, 2018. doi:10.1001/jamaoto.2018.3276

Importance  Tracheobronchomalacia (TBM) describes an increased collapsibility of the trachea and bronchi that is greatest on forced expiration. A broad term, TBM encompasses intrinsic tracheal weakness, some forms of tracheal deformation, and extrinsic compression. Tracheobronchomalacia is the most common congenital tracheal anomaly, affecting 1 in 2100 children. Tracheobronchomalacia is often associated with recurrent and prolonged respiratory tract infections, can lead to chronic lung disease, and can be fatal in its most severe form. Tracheobronchomalacia is often associated with other congenital anomalies and syndromes.

Observations  There is a paucity of information on TBM treatment in the modern otolaryngology literature. The primary treatment modalities described include tracheotomy, tracheal stents, and anterior aortopexy. In this review, a new TBM classification scheme and new treatment strategies are introduced to the otolaryngology literature. Diagnosis is made through history and physical examination, dynamic airway computed tomography, and dynamic 3-phase tracheobronchoscopy. Medical management includes nebulizer treatments, minimal use of inhaled corticosteroids, gastroesophageal reflux disease therapy, and continuous positive airway pressure. Surgical techniques, including anterior and posterior tracheobronchopexy and anterior and posterior aortopexy, are described.

Conclusions and Relevance  Tracheobronchomalacia is an entity of relevance to pediatric otolaryngologists and should be considered as being associated with respiratory distress, stridor, cough, recurrent pneumonia, or feeding difficulties, especially in children with syndromes or other congenital anomalies. A multidisciplinary approach to these patients is essential. A classification scheme facilitates discussion of individual patients among health care professionals and guides appropriate management. Novel surgical approaches for the treatment of TBM, including anterior and posterior tracheopexy and aortopexy, may be considered in management of the treatment of children with symptomatic TBM.