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. [11]
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. [12] 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. [13]
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 and Activity
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.
Further Care
Further outpatient care
No specific therapy or precautions are needed.
Provide outpatient care if bronchodilators are considered because they worsen the condition in some patients.
Follow the normal immunization schedule.
Reassurance during acute respiratory illnesses may be necessary. Babies may need to be seen frequently during these illnesses. During an upper respiratory infection, the normal cough sounds more crouplike in these children because the walls of the trachea appose during the cough. This also causes irritation in the tracheal walls, which prolongs the cough. The added pressures to overcome nasal obstruction adds to the dynamic collapse during the infection. As long as the baby is able to achieve adequate oral intake and is acting normally, intervention is usually not necessary.
Further inpatient care
Admission is not necessary unless the baby with tracheomalacia is having respiratory distress.
Inpatient and outpatient medications
No long-term medications are required. Consider systemic corticosteroids during a respiratory tract infection if the baby is having difficulty breathing.
Transfer
If the baby is having severe respiratory distress, transfer him or her to a pediatric intensive care unit.
-
Slide tracheoplasty and left PA sling repair. Procedure performed by Giles Peek MD, FRCS, CTh, FFICM, The Children’s Hospital at Montefiore, Bronx, NY.
-
This shows the trachea during inspiration and expiration. Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia.
