Tracheomalacia
Key points
Definition: Collapse of trachea due to deficiency of cartilage during expiration
Symptoms
Might be asymptomatic when not exerting
Stridor
Inability to complete feeds
Can sometimes present during inter current illness
Death
Symptoms may be less than degree seen on investigation
Can be mistaken for croup, but will not respond to adrenaline and steroids
Investigations
Bronchoscopy under GA, dynamic changes, buckling of cartilage + collapse of lumen
Then CT under GA - inspiratory and expiratory series. Look for vascular ring
MDT discussion - Surgery (if OA/TOF patient etc) ENT, ICU, Cardiology, Respiratory
Management
Can watch and wait, as airway calibre increases faster than child growth - should improve then resolve by 2 years
Can nurse prone
If recurrent admissions/life-threatening events - CPAP
Aortopexy
If >50% collapse of airway on bronchoscopy and symptomatic - Aortopexy can be considered
Aortopexy involves using sutures to lift the thoracic aorta forward, creating more space for trachea to expand
Approaches:
Suprasternal incision
Chamberlain
Anterolateral thoracotomy
Thoracoscopic
Some surgeons choose to do a hemithymectomy at the same time as aortopexy to create more room
Success rates for all approaches are same - based on case series
OA/TOF patients have best outcomes with Aortopexy, it may not help those with other syndromes
Bronchomalacia - unlikely aortopexy will work
Sometimes aortopexy can be bridge to lower airway stenting
Tracheopexy - stabilises trachea - can be anterior or posterior
References
Holcomb and Ashcraft’s Pediatric Surgery, 7th edition, 2020, Chapter 21 Management of Laryngotracheal obstruction in children