Interventions for primary (intrinsic) tracheomalacia in children

Abstract

BACKGROUND: Tracheomalacia, a disorder of the large airways where the trachea is deformed or malformed during respiration, is commonly seen in tertiary paediatric practice. It is associated with a wide spectrum of respiratory symptoms from life-threatening recurrent apnoea to common respiratory symptoms such as chronic cough and wheeze. Current practice following diagnosis of tracheomalacia includes medical approaches aimed at reducing associated symptoms of tracheomalacia, ventilation modalities of continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), and surgical approaches aimed at improving the calibre of the airway (airway stenting, aortopexy, tracheopexy We included one RCT that compared nebulized recombinant human deoxyribonuclease (rhDNase) with placebo in 40 children with airway malacia and a respiratory tract infection. We assessed it to be a RCT with overall low risk of bias. Data analyzed in this review showed that there was no significant difference between groups for the primary outcome of proportion cough-free at two weeks (odds ratio (OR) 1.38; 95% confidence interval (CI) 0.37 to 5.14). However, the mean change in night time cough diary scores significantly favoured the placebo group (mean difference (MD) 1.00; 95% CI 0.17 to 1.83, P = 0.02). The mean change in daytime cough diary scores from baseline was also better in the placebo group compared to those on nebulized rhDNase, but the difference between groups was not statistically significant (MD 0.70; 95% CI -0.19 to 1.59). Other outcomes (dyspnoea, and difficulty in expectorating sputum scores, and lung function tests at two weeks also favoured placebo over nebulized rhDNase but did not reach levels of significance. AUTHORS' CONCLUSIONS:There is currently an absence of evidence to support any of the therapies currently utilised for management of intrinsic tracheomalacia. It remains inconclusive whether the use of nebulized rhDNase in children with airway malacia and a respiratory tract infection worsens recovery. It is unlikely that any RCT on surgically based management will ever be available for children with severe life-threatening illness associated with tracheomalacia. For those with less severe disease, RCTs on interventions such as antibiotics and chest physiotherapy are clearly needed. Outcomes of these RCTs should include measurements of the trachea and physiological outcomes in addition to clinical outcomes. This is the abstract of a Cochrane Review published in the Cochrane Database of Systematic Reviews (CDSR) 2012, issue 10, art. No. CD005304.

Tracheal suspension by using 3-dimensional printed personalized scaffold in a patient with tracheomalacia

“…Anterior TM always occurs due to malformed tracheal cartilage, while posterior TM resulted from the membranous component. Currently there is no consensus regarding radiographic evaluation, standardized endoscopic evaluation, surgical approach, and medical treatments for TM (6). Multiple techniques have been created for the treatment of TM, however, there is currently no evidence supporting one therapy over another (6).…”

“…Currently there is no consensus regarding radiographic evaluation, standardized endoscopic evaluation, surgical approach, and medical treatments for TM (6). Multiple techniques have been created for the treatment of TM, however, there is currently no evidence supporting one therapy over another (6). The majority of methods are used to fix or stabilize the central airways and major bronchi, such as direct tracheobronchopexy, with either anterior suspension and/or posterior fixation for severe TM (12).…”

“…However, all these therapies have their instinct weakness, and the severe TM is lacking in an adequate intervention (6). Tracheostomy tube placement always accompanies tube occlusion with an incidence of 43%, which may cause…”

A new airway spiral stent designed to maintain airway architecture with an atraumatic removal after full epithelization—Research of feasibility and viability in canine patients with tracheomalacia

“…Currently, silicon stents and selfexpandable covered stents are being used, but mucosal obstruction, migration, and granuloma tissue development at the ends of the prosthesis are common complications. [14][15][16] Metallic stents, both balloon-expandable and self-expandable, reduce the likelihood of migration and improve mucus clearance; however, they can be fully epithelized and cannot be retrieved. [17][18][19] Recently, bioabsorbable airway stents have been implanted in children with tracheomalacia, and the results are promising.…”

Three-dimensional printing of external airway splints for tracheomalacia

“…Currently, there is little consensus on the evaluation, diagnosis, and treatment of severe tracheomalacia, including grading of symptom severity, criteria for radiographic or endoscopic evaluation, medical treatment, and surgical approach (3)(4)(5). According to the 2012 Cochrane review, there is no evidence to support any one therapy over another for the treatment of tracheomalacia (6).…”