eMedicine Specialties > Pediatrics: General Medicine > Pulmonology
Tracheomalacia: Treatment & Medication
Updated: Aug 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- After the diagnosis of tracheomalacia is made, the most effective and safest treatment is allowing time to pass ("tincture of time").
- 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.
- 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.4
- 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.
Medication
After the diagnosis of tracheomalacia is made, the most effective and safest treatment is the passage of time. Bronchodilators (eg, albuterol) usually do not help and may worsen tracheomalacia in some infants. The tone of the smooth muscle presumably stents the airway in some babies. Administering a beta-agonist relaxes these muscles and may worsen airway collapse.
Glucocorticoids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Babies who have respiratory difficulties during a concomitant upper respiratory tract infection may respond favorably to systemic corticosteroids. If the baby is noisier than usual but acting and eating normally, do not use medications.
Prednisolone (Orapred, Prelone, Pediapred)
May decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) activity. Available in tab and syr; prednisolone syr tastes better than prednisone syr.
Adult
5-60 mg/d PO qd or divided bid/tid/qid
Pediatric
2 mg/kg/d PO divided bid for 3-7 d; lower dose as quickly as possible to reduce adverse effects and complications; if used >10 d, attempt dosing qod (must gradually taper for discontinuation)
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, carbamazepine, or rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Prednisone (Deltasone, Meticorten, Orasone)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
5-60 mg/d PO qd or divided bid/tid/qid
Pediatric
2 mg/kg/d PO divided bid for 3-7 d; lower dose as quickly as possible to reduce adverse effects and complications; if used >10 d, attempt dosing qod (must gradually taper for discontinuation)
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, carbamazepine, or rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
More on Tracheomalacia |
| Overview: Tracheomalacia |
| Differential Diagnoses & Workup: Tracheomalacia |
 Treatment & Medication: Tracheomalacia |
| Follow-up: Tracheomalacia |
| Multimedia: Tracheomalacia |
| References |
| « Previous Page | Next Page » |
References
Boogaard R, Huijsmans SH, Pijnenburg MW, et al. Tracheomalacia and bronchomalacia in children: incidence and patient characteristics. Chest. Nov 2005;128(5):3391-7. [Medline].
Jamal N, Bent JP, Vicencio AG. A neurologic etiology for tracheomalacia?. Int J Pediatr Otorhinolaryngol. Jun 2009;73(6):885-7. [Medline].
Boiselle PM, Ernst A. Tracheal morphology in patients with tracheomalacia: prevalence of inspiratory lunate and expiratory "frown" shapes. J Thorac Imaging. Aug 2006;21(3):190-6. [Medline].
Vinograd I, Keidar S, Weinberg M, Silbiger A. Treatment of airway obstruction by metallic stents in infants and children. J Thorac Cardiovasc Surg. Jul 2005;130(1):146-50. [Medline].
Valerie EP, Durrant AC, Forte V, et al. A decade of using intraluminal tracheal/bronchial stents in the management of tracheomalacia and/or bronchomalacia: is it better than aortopexy?. J Pediatr Surg. Jun 2005;40(6):904-7; discussion 907. [Medline].
Austin J, Ali T. Tracheomalacia and bronchomalacia in children: pathophysiology, assessment, treatment and anaesthesia management. Paediatr Anaesth. Jan 2003;13(1):3-11. [Medline].
Casiano RR, Numa WA, Nurko YJ. Efficacy of transoral intraluminal Wallstents for tracheal stenosis or tracheomalacia. Laryngoscope. Oct 2000;110(10 Pt 1):1607-12. [Medline].
Dave S, Currie BG. The role of aortopexy in severe tracheomalacia. J Pediatr Surg. Mar 2006;41(3):533-7. [Medline].
Furman RH, Backer CL, Dunham ME, et al. The use of balloon-expandable metallic stents in the treatment of pediatric tracheomalacia and bronchomalacia. Arch Otolaryngol Head Neck Surg. Feb 1999;125(2):203-7. [Medline].
Inoue K, Yanagihara J, Ono S, et al. Utility of helical CT for diagnosis and operative planning in tracheomalacia after repair of esophageal atresia. Eur J Pediatr Surg. Dec 1998;8(6):355-7. [Medline].
Masters IB, Chang AB. Interventions for primary (intrinsic) tracheomalacia in children. Cochrane Database Syst Rev. 2005;CD005304. [Medline].
Panitch HB, Keklikian EN, Motley RA, et al. Effect of altering smooth muscle tone on maximal expiratory flows in patients with tracheomalacia. Pediatr Pulmonol. 1990;9(3):170-6. [Medline].
Vinograd I, Filler RM, Bahoric A. Long-term functional results of prosthetic airway splinting in tracheomalacia and bronchomalacia. J Pediatr Surg. Jan 1987;22(1):38-41. [Medline].
Yalcin E, Dogru D, Ozcelik U, et al. Tracheomalacia and bronchomalacia in 34 children: clinical and radiologic profiles and associations with other diseases. Clin Pediatr (Phila). Nov-Dec 2005;44(9):777-81. [Medline].
Further Reading
Keywords
tracheomalacia, tracheal wall collapse, airway obstruction, airway compression, compression of the airway, asthma, chronic asthma, bronchiolitis, vascular ring and sling, vascular sling and ring, tracheoesophageal fistula, gastroesophageal reflux, GER, gastroesophageal reflux disease, GERD, wheeze, wheezing, happy wheezer, treatment, diagnosis
