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Pugh CP, Akmyradov C, Courtney SE, Agarwal A, Chandler A, Matlock DN. The effect of bethanechol on tracheobronchomalacia in preterm infants with bronchopulmonary dysplasia: a retrospective cohort study. J Perinatol 2024; 44:288-293. [PMID: 37848605 DOI: 10.1038/s41372-023-01799-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Bethanechol has demonstrated improvement in trachealis tone in animal models, but no trials have studied efficacy in infants. This study aimed to examine if bethanechol improves a standardized pulmonary severity score (PSS) in infants with severe bronchopulmonary dysplasia with a diagnosis of tracheobronchomalacia (TBM). STUDY DESIGN This retrospective cohort study evaluated cases treated with bethanechol matched with controls who did not receive bethanechol. TBM was diagnosed by dynamic computography. Daily PSS was recorded for each infant from 40 to 55 weeks post-menstrual age. RESULTS Cases' mean PSS change was 21% lower than the controls' mean PSS change pre- and post-bethanechol (95% CI -40%, -2%) by paired t-test (p = 0.03). Matched differences (controls' PSS - cases' PSS) demonstrated greater mean PSS difference post-bethanechol compared to pre-bethanechol 0.17, (95% CI 0.05, 0.29) by paired t-test (p = 0.009). CONCLUSION Infants with TBM treated with bethanechol compared to those not treated had a lower PSS reflecting improved respiratory status.
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Affiliation(s)
- C Preston Pugh
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Chary Akmyradov
- Biostatistics, Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Sherry E Courtney
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Amit Agarwal
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Angela Chandler
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David N Matlock
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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O'Shea D, Schmoke N, Porigow C, Murray LP, Chung WK, Kattan M, Jang M, Antosy A, Middlesworth W, Khlevner J. Recent Advances in the Genetic Pathogenesis, Diagnosis, and Management of Esophageal Atresia and Tracheoesophageal Fistula: A Review. J Pediatr Gastroenterol Nutr 2023; 77:703-712. [PMID: 37771007 DOI: 10.1097/mpg.0000000000003952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Infants born with esophageal atresia and tracheoesophageal fistula, a complex congenital malformation occurring in 1/2500-4000 live births, may suffer threats to their cardiac, respiratory, and digestive health in addition to anomalies that may exist in the genitourinary and musculoskeletal systems. Optimal care for these patients throughout their lives is best achieved through a coordinated, multidisciplinary approach that our health care system is not always well-equipped to provide. This review, though not exhaustive, highlights the components of care that pertain to initial surgical reconstruction and subsequent diagnosis and management of the complications that are most frequently encountered. Authors from among the many specialties involved in the care of these patients summarize the current best practice with attention to the most recent advances. Assessment and improvement of quality of life and transition to adult specialists as children grow to adulthood is also reviewed.
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Affiliation(s)
- Delia O'Shea
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Nicholas Schmoke
- the Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Chloe Porigow
- the Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Laurie P Murray
- the Division of Pediatric Pulmonology, Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Wendy K Chung
- the Department of Pediatrics and Medicine, Columbia University Irving Medical Center, New York, NY
| | - Meyer Kattan
- the Division of Pediatric Pulmonology, Department of Pediatrics, Columbia University Irving Medical Center/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Minyoung Jang
- the Department of Otolaryngology Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Alexandra Antosy
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - William Middlesworth
- the Division of Pediatric Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Julie Khlevner
- From the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
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3
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Md JNG, Ransom M, Kaspar A, Wilcox LJ, Whigham AS, Engelstad HJ. Neonatal Laryngotracheal Anomalies. Neoreviews 2022; 23:e613-e624. [PMID: 36047759 DOI: 10.1542/neo.23-9-e613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Respiratory distress in the neonate is one of the most common reasons for referral to a tertiary NICU, accounting for more than 20% of admissions. (1) The cause of respiratory distress can range from parenchymal lung disease to anomalies of any portion of the neonatal airway including the nose, pharynx, larynx, trachea, or bronchi. This review will focus on airway anomalies at or immediately below the level of the larynx. Although rare, those with such congenital or acquired laryngotracheal anomalies often require urgent evaluation and surgical intervention. This review describes 1) the pathophysiology associated with congenital and acquired laryngotracheal deformities in the neonate, 2) the clinical presentation and diagnostic evaluation of these anomalies, and 3) the current medical and surgical strategies available in the NICU and after discharge.
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Affiliation(s)
- Jean-Nicolas Gallant Md
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Meaghan Ransom
- Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Ashley Kaspar
- Department of Therapy and Rehabilitation, Dell Children's Medical Center, Austin, TX
| | - Lyndy J Wilcox
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Amy S Whigham
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Holly J Engelstad
- Division of Neonatology, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
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Baker CD. Chronic respiratory failure in bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:3490-3498. [PMID: 33666365 DOI: 10.1002/ppul.25360] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 11/09/2022]
Abstract
Although survival has improved dramatically for extremely preterm infants, those with the most severe forms of bronchopulmonary dysplasia (BPD) fail to improve in the neonatal period and go on to develop chronic respiratory failure. When careful weaning of respiratory support is not tolerated, the difficult decision of whether or not to pursue chronic ventilation via tracheostomy must be made. This requires shared decision-making with an interdisciplinary medical team and the child's family. Although they suffer from increased morbidity and mortality, the majority of these children will survive to tolerate ventilator liberation and tracheostomy decannulation. Care coordination for the technology-dependent preterm infant is complex, but there is a growing consensus that chronic ventilation can best support neurodevelopmental progress and improve long-term outcomes.
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Affiliation(s)
- Christopher D Baker
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Hysinger EB. Central airway issues in bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:3518-3526. [PMID: 33835725 PMCID: PMC8656371 DOI: 10.1002/ppul.25417] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/10/2021] [Indexed: 11/10/2022]
Abstract
While there is a very large focus on the abnormalities of parenchymal lung development and extensive efforts to minimize alveolar damage with "gentle ventilation" and noninvasive respiratory support for neonates with bronchopulmonary dysplasia (BPD), there is relatively little consideration for the implications of central airway disease in this patient population. There are significant changes in the structure and conformation of the central airway during the last half of gestation, and premature birth disrupts this natural developmental process. The arrest of maturation results in a smaller airway that is more compliant, easier to deform, and more susceptible to damage. Consequently, neonates with BPD are prone to developing central airway pathology, particularly for patients who require intubation and positive pressure ventilation. Central airway disease can be divided into dynamic and fixed airway obstruction and results in increased respiratory morbidity in neonates with chronic lung disease of prematurity.
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Affiliation(s)
- Erik B Hysinger
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Riding a New Wave: Computational Fluid Dynamics Brings Clinical Trials for Tracheomalacia within Reach. Ann Am Thorac Soc 2020; 17:1209-1210. [PMID: 33000961 PMCID: PMC7640623 DOI: 10.1513/annalsats.202007-847ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Koumbourlis AC, Belessis Y, Cataletto M, Cutrera R, DeBoer E, Kazachkov M, Laberge S, Popler J, Porcaro F, Kovesi T. Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula. Pediatr Pulmonol 2020; 55:2713-2729. [PMID: 32716120 DOI: 10.1002/ppul.24982] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/18/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
Abstract
Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.
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Affiliation(s)
- Anastassios C Koumbourlis
- Division of Pulmonary & Sleep Medicine, Children's National Hospital, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Yvonne Belessis
- Department of Respiratory Medicine, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Mary Cataletto
- Division of Pediatric Pulmonary Medicine, New York University, Winthrop University Hospital, Mineola, New York
| | - Renato Cutrera
- Academic Department of Pediatrics (DPUO), Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Pediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Emily DeBoer
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Denver, Children's Hospital Colorado Breathing Institute, Aurora, Colorado
| | - Mikhail Kazachkov
- Department of Pediatric Pulmonology, Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, New York
| | - Sophie Laberge
- Department of Pediatrics, Division of Respiratory Medicine, Sainte-Justine University Hospital Center, Université de Montréal, Montreal, Quebec, Canada
| | - Jonathan Popler
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Federica Porcaro
- Department of Pediatrics, Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Thomas Kovesi
- Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
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Ramphul M, Bush A, Chang A, Prifits KN, Wallis C, Bhatt JM. The role of the pediatrician in caring for children with tracheobronchomalacia. Expert Rev Respir Med 2020; 14:679-689. [DOI: 10.1080/17476348.2020.1750374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Manisha Ramphul
- Queens Medical Centre, Nottingham University Hospitals, Nottingham, UK
| | - Andrew Bush
- Imperial College, London, UK
- Royal Brompton & Harefield NHS Foundation Trust, Royal Brompton Hospital, London, UK
| | - Anne Chang
- Department of Respiratory and Sleep Medicine, Queensland Children’s Hospital, Children Centre for Health Research, Queensland University of Technology, Brisbane, Australia
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Kostas N Prifits
- Allergy - Pulmonology Unit, 3rd Dept Paediatrics, Athens University Medical School, Chaidari, Greece
| | - Colin Wallis
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jayesh Mahendra Bhatt
- Department of Paediatric Respiratory Medicine, Nottingham Children’s Hospital, Nottingham University Hospitals, Queens Medical Centre, Nottingham, UK
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