Pediatric Tracheomalacia Treatment & Management
- Author: Michael R Bye, MD; Chief Editor: Michael R Bye, MD more...
Medical Care
After the diagnosis of tracheomalacia is made, the most effective and safest treatment is allowing time to pass ("tincture of time"). Some have recommended that before considering a surgical approach, other therapies, including noninvasive ventilation, should be used, given the transient nature of the disorder.[4]
Bronchodilators do not help and sometimes worsen the tracheomalacia. The tone of the smooth muscle helps stent the airway. Administering a beta-agonist relaxes the smooth muscle and may worsen collapse of the airway.
If the child is having difficulty with retained secretions, chest physiotherapy may be helpful.
If gastroesophageal reflux is present, appropriate pharmacotherapy should be considered.
On occasion, systemic corticosteroids are used when the baby has increased symptoms during an acute respiratory tract infection. These drugs should be reserved for episodes in which the tracheomalacia interferes with the child's oral intake or disposition or when the child develops respiratory difficulty.
If the child is making more noise but is otherwise doing well, steroids can usually be avoided.
One group showed that positive expiratory pressure during an illness improved the cough flow rates in children with tracheomalacia, making the chest physical therapy and cough itself more effective.[5] Continuous positive airway pressure or bilevel positive airway pressure provided by means of tight-fitting face or nasal mask, endotracheal tube, or tracheostomy tube can provide relief from severe obstruction.
Surgical Care
Surgery may be an option when the baby has one or all of the following:
- Difficulty gaining weight and developing
- Recurrent pneumonia or apnea
- Enough airway obstruction to require long-term airway support
Tracheostomy can provide internal stenting of the trachea in babies with any of the findings above. With time and growth, the airway obstruction resolves, and the cannula can be removed from the infant.
In aortopexy, the aortic arch is lifted off the trachea. This has resulted in symptomatic improvement in many children.
Recent success with metal stents in young children has been described.[6]
Repair of vascular rings and slings can be done to decompress the trachea and allow healing to begin.
Consultations
- Because the expiratory noise has clinically significant differential diagnoses, refer the baby whose wheeze does not remit with good asthma therapy to a pediatric pulmonologist.
- Bronchoscopy ensures a definitive diagnosis in an infant who is otherwise well. A sweat test, esophagraphy, echocardiography, and/or chest CT scanning may otherwise be necessary.
Diet
- No dietary restrictions or changes are necessary.
Activity
- No restrictions or changes are necessary.
- The abnormal airway dynamics may persist even after the clinical findings have remitted. If symptoms persist with exercise as the patient ages, an exercise test is indicated to make sure that minute ventilation increases appropriately with exercise.
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