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Kennelly SS, Hovland V, Matthews IL, Reinholt FP, Skjerven H, Heimdal K, Crowley S. Tracheobronchomalacia is common in children with primary ciliary dyskinesia-A case note review. Pediatr Pulmonol 2024. [PMID: 39291788 DOI: 10.1002/ppul.27262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 07/06/2024] [Accepted: 09/03/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND The estimated prevalence of tracheobronchomalacia (TBM) in children is about 1:2100. Prevalence of intrathoracic malacia is higher in children with chronic lung disease such as bronchiectasis and cystic fibrosis (CF) and may contribute to increased morbidity. OBJECTIVE To determine the prevalence and assess clinical features of tracheomalacia (TM), TBM and bronchomalacia (BM) in patients with primary ciliary dyskinesia (PCD). METHODS We performed a retrospective case-note review of all children with a confirmed or highly likely diagnosis of PCD attending Oslo University Hospital between 2000 and 2021. We selected those who had undergone flexible fiberoptic bronchoscopy (FB) and in whom the presence of TBM was assessed. We retrieved demographic and clinical data, including airway symptoms, PCD-diagnostic criteria, indication for bronchoscopy, the presence of lobar atelectasis, microbiology and the descriptive and unblinded video-recorded results of FB. Complications occurring during and after bronchoscopy were noted. RESULTS Of 71 children with PCD, 32 underwent FB and were included in the review. The remaining 39 were included for TBM prevalence calculation only. Median age at FB was 6.0 years (3.1-11.9). Twenty-two children (69%) had intrathoracic airway malacia. Four (13%) had isolated TM, seven (22%) had TBM, and 11 (34%) had isolated BM affecting either main (n = 4) or lobar bronchi (n = 7) (LBM), including four with associated lobar atelectasis. FB related complications, one major, 12 minor, were documented in 13 children (41%). CONCLUSION We found a high prevalence of TBM among children with PCD undergoing FB. This may represent a significant comorbidity and have implications for patient management.
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Affiliation(s)
- Synne S Kennelly
- Paediatric Department of Allergy and Lung Diseases, Oslo University Hospital, Oslo, Norway
- Division of Paediatric and Adolescent Medicine, Department of Paediatric Training and Education, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Vegard Hovland
- Paediatric Department of Allergy and Lung Diseases, Oslo University Hospital, Oslo, Norway
| | - Iren Lindbak Matthews
- Paediatric Department of Allergy and Lung Diseases, Oslo University Hospital, Oslo, Norway
| | - Finn P Reinholt
- Department of Pathology, Core Facility of Electron Microscopy, Oslo University Hospital, Oslo, Norway
| | - Håvard Skjerven
- Paediatric Department of Allergy and Lung Diseases, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Paediatric and Adolescent Medicine, Department of Paediatric Research, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Ketil Heimdal
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Suzanne Crowley
- Paediatric Department of Allergy and Lung Diseases, Oslo University Hospital, Oslo, Norway
- Norwegian Center for Cystic Fibrosis, Oslo University Hospital, Oslo, Norway
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Almogarry L, Alradhi A, Alshamrani AS. Isolated Tracheabronchomalacia Misdiagnosed for Years as Bronchial Asthma. Cureus 2023; 15:e35641. [PMID: 36875250 PMCID: PMC9976646 DOI: 10.7759/cureus.35641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Abstract
Tracheomalacia (TM) is an abnormal collapse of the tracheal lumen, which often occurs when the cartilaginous part of the trachea has not developed. It is a rare condition but is seen often in infancy and childhood period. The incidence of primary airway malacia in children was estimated to be at least one in 2,100. It has a wide range of etiologies, and it is often localized but rarely generalized as in our case. It could be severe enough to indicate frequent admission and might expose the patient to multiple unnecessary medications. We are reporting a case with unusual primary tracheobronchomalacia (TBM) that was missed for several years with a huge burden on both families and healthcare providers. A five-year-old Saudi girl had multiple admissions to the intensive care unit with similar presentation each time, and she was misdiagnosed as having asthma exacerbation with an occasional chest infection. Bronchoscopy revealed the underlying condition, and the patient was kept on the minimal intervention of nasal continuous positive airway pressure (CPAP) and aggressive airway hydration therapy, all with the goal of improving the patient's outcome and reducing hospital admissions. We emphasize the importance of alerting physicians about malacia as an important cause of recurrent wheezy chest, which is one of the common asthma mimickers; in such cases, flexible bronchoscopy remains the gold standard diagnostic test, while the treatment remained supportive.
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Affiliation(s)
- Lubna Almogarry
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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Koenigs M, Young C, Lillis A, Morrison J, Kelly N, Elmaraghy C, Krishnamurthy R, Chiang T. Dynamic Volumetric Computed Tomography Angiography is an Effective Method to Evaluate Tracheomalacia in Children. Laryngoscope 2023; 133:410-416. [PMID: 35411953 PMCID: PMC10792495 DOI: 10.1002/lary.30125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Standard methods to evaluate tracheal pathology in children, including bronchoscopy, may require general anesthesia. Conventional dynamic proximal airway imaging in noncooperative children requires endotracheal intubation and/or medically induced apnea, which may affect airway mechanics and diagnostic performance. We describe a technique for unsedated dynamic volumetric computed tomography angiography (DV-CTA) of the proximal airway and surrounding vasculature in children and evaluate its performance compared to the reference-standard of rigid bronchoscopy. METHODS Children who had undergone DV-CTA and bronchoscopy in one-year were retrospectively identified. Imaging studies were reviewed by an expert reader blinded to the bronchoscopy findings of primary or secondary tracheomalacia. Airway narrowing, if present, was characterized as static and/or dynamic, with tracheomalacia defined as >50% collapse of the tracheal cross-sectional area in exhalation. Pearson correlation was used for comparison. RESULTS Over a 19-month period, we identified 32 children (median age 8 months, range 3-14 months) who had undergone DV-CTA and bronchoscopy within a 90-day period of each other. All studies were unsedated and free-breathing. The primary reasons for evaluation included noisy breathing, stridor, and screening for tracheomalacia. There was excellent agreement between DV-CTA and bronchoscopy for diagnosis of tracheomalacia (κ = 0.81, p < 0.001), which improved if children (n = 25) had the studies within 30 days of each other (κ = 0.91, p < 0.001). CTA provided incremental information on severity, and cause of secondary tracheomalacia. CONCLUSION For most children, DV-CTA requires no sedation or respiratory manipulation and correlates strongly with bronchoscopy for the diagnosis of tracheomalacia. LEVEL OF EVIDENCE 3 Laryngoscope, 133:410-416, 2023.
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Affiliation(s)
- Maria Koenigs
- The Warren Alpert Medical School of Brown University, Providence, U.S.A
- Department of Otolaryngology - Head and Neck Surgery, Hasbro Children's Hospital, Providence, U.S.A
| | - Cody Young
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Anna Lillis
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Jessica Morrison
- Department of Radiology, Nationwide Children's Hospital, Columbus, U.S.A
| | - Natalie Kelly
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Charles Elmaraghy
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Rajesh Krishnamurthy
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
| | - Tendy Chiang
- Department of Otolaryngology - Head and Neck Surgery, Nationwide Children's Hospital, Columbus, U.S.A
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Boonjindasup W, Marchant JM, McElrea MS, Yerkovich ST, Thomas RJ, Masters IB, Chang AB. Pulmonary function of children with tracheomalacia and associated clinical factors. Pediatr Pulmonol 2022; 57:2437-2444. [PMID: 35785487 PMCID: PMC9796637 DOI: 10.1002/ppul.26054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/01/2022] [Accepted: 06/25/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Spirometry is easily accessible yet there is limited data in children with tracheomalacia. Availability of such data may inform clinical practice. We aimed to describe spirometry indices of children with tracheomalacia, including Empey index and flow-volume curve pattern, and determine whether these indices relate with bronchoscopic features. METHODS From the database of children with tracheomalacia diagnosed during 2016-2019, we reviewed their flexible bronchoscopy and spirometry data in a blinded manner. We specially evaluated several spirometry indices and tracheomalacia features (cross-sectional lumen reduction, malacic length, and presence of bronchomalacia) and determined their association using multivariable regression. RESULTS Of 53 children with tracheomalacia, the mean (SD) peak expiratory flow (PEF) was below the normal range [68.9 percent of predicted value (23.08)]. However, all other spirometry parameters were within normal range [Z-score forced expired volume in 1 s (FEV1 ) = -1.18 (1.39), forced vital capacity (FVC) = -0.61 (1.46), forced expiratory flow between 25% and 75% of vital capacity (FEF25%-75% ) = -1.43 (1.10), FEV1 /FVC = -1.04 (1.08)], Empey Index = 8.21 (1.59). The most common flow-volume curve pattern was the "knee" pattern (n = 39, 73.6%). Multivariable linear regression identified the presence of bronchomalacia was significantly associated with lower flows: FEV1 [coefficient (95% CI) -0.78 (-1.54, -0.02)], FEF25%-75% [-0.61 (-1.22, 0)], and PEF [-12.69 (-21.13, -4.25)], all p ≤ 0.05. Other bronchoscopic-defined tracheomalacia features examined (cross-sectional lumen reduction, malacic length) were not significantly associated with spirometry indices. CONCLUSION The "knee" pattern in spirometry flow-volume curve is common in children with tracheomalacia but other indices, including Empey index, cannot be used to characterize tracheomalacia. Spirometry indices were not significantly associated with bronchoscopic tracheomalacia features but children with tracheobronchomalacia have significantly lower flow than those with tracheomalacia alone.
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Affiliation(s)
- Wicharn Boonjindasup
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julie M Marchant
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Margaret S McElrea
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Stephanie T Yerkovich
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Rahul J Thomas
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Ian B Masters
- Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Anne B Chang
- Menzies School of Health Research, Child Health Division, NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Charles Darwin University, Casuarina, Northern Territory, Australia.,Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia
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5
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Sodhi KS, Saini S, Bhatia A, Mathew JL, Saxena AK, Singh M. Four-Dimensional Dynamic Airway Imaging: New Noninvasive Tool in Pediatric Patients With Stridor. Pediatr Emerg Care 2021; 37:e893-e894. [PMID: 34772879 DOI: 10.1097/pec.0000000000002575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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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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Komura M, Komura H, Ishimaru T, Konishi K, Komuro H, Hoshi K, Takato T. Tracheal cartilage growth promotion by intra-tracheal administration of basic FGF. Pediatr Surg Int 2020; 36:33-41. [PMID: 31555864 DOI: 10.1007/s00383-019-04576-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to investigate whether intra-tracheal administration of basic fibroblast growth factor (b-FGF) promotes the growth of tracheal cartilage. METHODS Trachea of 4-week old mice were intubated and 2.5 μg b-FGF administered (Group 4) for periods from 1 to 5 days. Cervical tracheal outer diameter and tracheal ring length were compared in Group 1 (no intervention), Group 2 (tracheal intubation), Group 3 (intra-tracheal administration of distilled water) and Group 4, at 8 weeks of age. Outer diameter and tracheal ring length in Group 4 were also compared with that in Group 1 at 12 and 16 weeks of age. RESULTS At 8 weeks of age, tracheal ring length with b-FGF administration for more than 4 days in Group 4 was significantly increased over that following 1-day administration. At 8 weeks of age, mean outer diameter and the mean tracheal ring length in Group 4 were significantly greater than in the other groups. Mean outer diameter and mean tracheal ring length were significantly greater in Group 4 than in Group 1 at 12 and 16 weeks of age. CONCLUSION This study has shown that intra-tracheal administration of b-FGF enlarges the tracheal lumen.
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Affiliation(s)
- Makoto Komura
- Department of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. .,Department of Pediatric Surgery, Saitama Medical University, Morohongou 38, Moroyama-chou, Iruma-gun, Saitama, 350-0495, Japan. .,Department of Tissue Engineering, Tokyo University Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Hiroko Komura
- Department of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kenichiro Konishi
- Department of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroaki Komuro
- Department of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuto Hoshi
- Department of Tissue Engineering, Tokyo University Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tsuyoshi Takato
- Department of Tissue Engineering, Tokyo University Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Wallis C, Alexopoulou E, Antón-Pacheco JL, Bhatt JM, Bush A, Chang AB, Charatsi AM, Coleman C, Depiazzi J, Douros K, Eber E, Everard M, Kantar A, Masters IB, Midulla F, Nenna R, Roebuck D, Snijders D, Priftis K. ERS statement on tracheomalacia and bronchomalacia in children. Eur Respir J 2019; 54:13993003.00382-2019. [PMID: 31320455 DOI: 10.1183/13993003.00382-2019] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/16/2019] [Indexed: 01/20/2023]
Abstract
Tracheomalacia and tracheobronchomalacia may be primary abnormalities of the large airways or associated with a wide variety of congenital and acquired conditions. The evidence on diagnosis, classification and management is scant. There is no universally accepted classification of severity. Clinical presentation includes early-onset stridor or fixed wheeze, recurrent infections, brassy cough and even near-death attacks, depending on the site and severity of the lesion. Diagnosis is usually made by flexible bronchoscopy in a free-breathing child but may also be shown by other dynamic imaging techniques such as low-contrast volume bronchography, computed tomography or magnetic resonance imaging. Lung function testing can provide supportive evidence but is not diagnostic. Management may be medical or surgical, depending on the nature and severity of the lesions, but the evidence base for any therapy is limited. While medical options that include bronchodilators, anti-muscarinic agents, mucolytics and antibiotics (as well as treatment of comorbidities and associated conditions) are used, there is currently little evidence for benefit. Chest physiotherapy is commonly prescribed, but the evidence base is poor. When symptoms are severe, surgical options include aortopexy or posterior tracheopexy, tracheal resection of short affected segments, internal stents and external airway splinting. If respiratory support is needed, continuous positive airway pressure is the most commonly used modality either via a face mask or tracheostomy. Parents of children with tracheobronchomalacia report diagnostic delays and anxieties about how to manage their child's condition, and want more information. There is a need for more research to establish an evidence base for malacia. This European Respiratory Society statement provides a review of the current literature to inform future study.
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Affiliation(s)
- Colin Wallis
- Respiratory Medicine Unit, Great Ormond Street Hospital for Children, London, UK
| | - Efthymia Alexopoulou
- 2nd Radiology Dept, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Juan L Antón-Pacheco
- Pediatric Airway Unit and Pediatric Surgery Division, Universidad Complutense de Madrid, Madrid, Spain
| | - Jayesh M Bhatt
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Andrew Bush
- Imperial College London and Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anne B Chang
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia.,Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Casuarina, Australia
| | | | | | - Julie Depiazzi
- Physiotherapy Dept, Perth Children's Hospital, Perth, Australia
| | - Konstantinos Douros
- Allergology and Pulmonology Unit, 3rd Paediatric Dept, National and Kapodistrian University of Athens, Athens, Greece
| | - Ernst Eber
- Division of Paediatric Pulmonology and Allergology, Dept of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Mark Everard
- Division of Paediatrics, University of Western Australia, Perth Children's Hospital, Perth, Australia
| | - Ahmed Kantar
- Pediatric Asthma and Cough Centre, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
| | - Ian B Masters
- Dept of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia.,Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Fabio Midulla
- Dept of Paediatrics, "Sapienza" University of Rome, Rome, Italy
| | - Raffaella Nenna
- Dept of Paediatrics, "Sapienza" University of Rome, Rome, Italy.,Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Derek Roebuck
- Interventional Radiology Dept, Great Ormond Street Hospital, London, UK
| | - Deborah Snijders
- Dipartimento Salute della Donna e del Bambino, Università degli Studi di Padova, Padova, Italy
| | - Kostas Priftis
- Allergology and Pulmonology Unit, 3rd Paediatric Dept, National and Kapodistrian University of Athens, Athens, Greece
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Douros K, Kremmydas G, Grammeniatis V, Papadopoulos M, Priftis KN, Alexopoulou E. Helical multi-detector CT scan as a tool for diagnosing tracheomalacia in children. Pediatr Pulmonol 2019; 54:47-52. [PMID: 30485735 DOI: 10.1002/ppul.24188] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 10/01/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND/AIMS Tracheomalacia (TM) is not an unusual diagnosis in pediatric respiratory clinics. The aim of this study was to assess the accuracy of paired static end-inspiratory/end-expiratory helical multi-detector CT scan (MDCT) in detecting TM. METHODS FB was performed in 28 children suspected of TM on the grounds of presence of recurrent episodes of vibrating cough and a need for more specific diagnostic information. Children diagnosed with flexible bronchoscopy (FB) as having TM were further investigated with MDCT. The cross-sectional area ratio of the trachea during end-expiration and end-inspiration, at the level of maximum end-expiration collapse (CSR), determined the basis for the MDCT diagnosis of TM. FB and MDCT were also performed in five children who suffered from mainly dry-but not honking, barking, or vibrating-cough for more than 3 months, and served as controls. RESULTS The diagnosis of TM was established bronchoscopically in 26 out of 28 children. CRS was significantly smaller in patients (0.59 ± 0.14) compared with controls (0.85 ± 0.11) (P = 0.001). The optimal CSR cut-off point for TM diagnosis, as it was estimated by the ROC curve, was ≤0.705 (95%CI: ≤0.635-≤0.850) with a sensitivity 84.6% (95%CI: 65.1-95.6), and specificity 100.0% (95%CI: 47.8-100.0). CONCLUSIONS MDCT can effectively diagnose TM in the majority of children and can be used as an alternative to FB. In children, the established criterion of CSR ≤0.5 should be replaced by CSR ≤0.7 that seems to be a more appropriate threshold.
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Affiliation(s)
- Konstantinos Douros
- Allergology and Pulmonology Unit, 3rd Pediatric Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Kremmydas
- Second Department of Radiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilis Grammeniatis
- Allergology and Pulmonology Unit, 3rd Pediatric Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marios Papadopoulos
- Allergology and Pulmonology Unit, 3rd Pediatric Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kostas N Priftis
- Allergology and Pulmonology Unit, 3rd Pediatric Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efthymia Alexopoulou
- Second Department of Radiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
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10
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Leong P, Tran A, Rangaswamy J, Ruane LE, Fernando MW, MacDonald MI, Lau KK, Bardin PG. Expiratory central airway collapse in stable COPD and during exacerbations. Respir Res 2017; 18:163. [PMID: 28841915 PMCID: PMC5574204 DOI: 10.1186/s12931-017-0646-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 08/21/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Tracheal obstruction resulting from expiratory tracheal deformation has been associated with respiratory symptoms and severe airway exacerbations. In chronic obstructive pulmonary disease (COPD), acute exacerbations (AECOPD) create large intrathoracic pressure swings which may increase tracheal deformation. Excessive central airway collapse (ECAC) may be diagnosed when the tracheal area on expiration is less than 50% of that on inspiration. The prevalence of ECAC in AECOPD and its temporal course have not been systematically studied. METHODS We prospectively recruited healthy volunteers (n = 53), stable outpatients with COPD (n = 40) and patients with hospitalised acute exacerbations of COPD (AECOPD, n = 64). 17 of the AECOPD group returned for repeat evaluation when clinically well at 6-12 weeks. All subjects underwent dynamic 320-slice computed tomography of the larynx and trachea during tidal breathing, enabling quantitation of tracheal area and dimensions (mean ± SD). RESULTS No healthy individuals had ECAC. The prevalence of ECAC in stable COPD and AECOPD was 35% and 39% respectively. Mean tracheal collapse did not differ between stable COPD (57.5 ± 19.8%), AECOPD (53.8 ± 19.3%) and in the subset who returned when convalescent (54.9 ± 17.2%). AECOPD patients with and without ECAC had similar clinical characteristics. CONCLUSIONS Tracheal collapse in both stable and AECOPD is considerably more prevalent than in healthy individuals. ECAC warrants assessment as part of comprehensive COPD evaluation and management. Further studies should evaluate the aetiology of ECAC and whether it predisposes to exacerbations.
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Affiliation(s)
- Paul Leong
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
- Monash University, Clayton, VIC Australia
| | - Anne Tran
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Jhanavi Rangaswamy
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Laurence E. Ruane
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Michael W. Fernando
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Martin I. MacDonald
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
| | - Kenneth K. Lau
- Monash University, Clayton, VIC Australia
- Diagnostic Imaging, Monash Medical Centre, Clayton, Australia
| | - Philip G. Bardin
- Monash Lung and Sleep, Monash Medical Centre, 246 Clayton Road, Clayton, 3168 Australia
- Monash University, Clayton, VIC Australia
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Deacon JWF, Widger J, Soma MA. Paediatric tracheomalacia - A review of clinical features and comparison of diagnostic imaging techniques. Int J Pediatr Otorhinolaryngol 2017; 98:75-81. [PMID: 28583509 DOI: 10.1016/j.ijporl.2017.04.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 04/16/2017] [Accepted: 04/18/2017] [Indexed: 11/17/2022]
Affiliation(s)
| | - John Widger
- Paediatric Respiratory Medicine, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Child's Health, University of New South Wales, Australia
| | - Marlene A Soma
- School of Women's and Child's Health, University of New South Wales, Australia; Paediatric Otolaryngology, Sydney Children's Hospital, Randwick, NSW, Australia
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Su SC, Masters IB, Buntain H, Frawley K, Sarikwal A, Watson D, Ware F, Wuth J, Chang AB. A comparison of virtual bronchoscopy versus flexible bronchoscopy in the diagnosis of tracheobronchomalacia in children. Pediatr Pulmonol 2017; 52:480-486. [PMID: 27641078 DOI: 10.1002/ppul.23606] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/11/2016] [Accepted: 09/06/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Flexible bronchoscopy (FB) is the current gold standard for diagnosing tracheobronchomalacia. However, it is not always feasible and virtual bronchoscopy (VB), acquired from chest multi-detector CT (MDCT) scan is an alternative diagnostic tool. We determined the sensitivity, specificity, and positive and negative predictive values of VB compared to FB in diagnosing tracheobronchomalacia. METHODS Children aged <18-years scheduled for FB and MDCT were recruited. FB and MDCT were undertaken within 30-min to 7-days of each other. Tracheobronchomalacia (mild, moderate, severe, very severe) diagnosed on FB were independently scored by two pediatric pulmonologists; VB was independently scored by two pairs (each pair = pediatric pulmonologist and radiologist), in a blinded manner. RESULTS In 53 children (median age = 2.5 years, range 0.8-14.3) evaluated for airway abnormalities, tracheomalacia was detected in 37 (70%) children at FB. Of these, VB detected tracheomalacia in 20 children, with a sensitivity of 54.1% (95%CI 37.1-70.2), specificity = 87.5% (95%CI 60.4-97.8), and positive predictive value = 90.9% (95%CI 69.4-98.4). The agreement between pediatric pulmonologists for diagnosing tracheomalacia by FB was excellent, weighted κ = 0.8 (95%CI 0.64-0.97); but only fair between the pairs of pediatric pulmonologists/radiologists for VB, weighted κ = 0.47 (95%CI 0.23-0.71). There were 42 cases of bronchomalacia detected on FB. VB had a sensitivity = 45.2% (95%CI 30.2-61.2), specificity = 95.5% (95%CI 94.2-96.5), and positive predictive value = 23.2 (95%CI 14.9-34.0) compared to FB in detecting bronchomalacia. CONCLUSION VB cannot replace FB as the gold standard for detecting tracheobronchomalacia in children. However, VB could be considered as an alternative diagnostic modality in children with symptoms suggestive of tracheobronchomalacia where FB is unavailable. Pediatr Pulmonol. 2017;52:480-486. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Siew Choo Su
- Queensland Children's Respiratory Centre and Children's Centre Health Research, Brisbane, Queensland, Australia.,Respiratory Unit, Department of Pediatrics, Hospital Tengku Ampuan Rahimah, Jalan Langat, Klang 41200, Selangor, Malaysia
| | - Ian Brent Masters
- Queensland Children's Respiratory Centre and Children's Centre Health Research, Brisbane, Queensland, Australia
| | - Helen Buntain
- Queensland Children's Respiratory Centre and Children's Centre Health Research, Brisbane, Queensland, Australia
| | - Kieran Frawley
- Department of Medical Imaging and Nuclear Medicine, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Anubhav Sarikwal
- Department of Medical Imaging and Nuclear Medicine, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Debbie Watson
- Department of Medical Imaging and Nuclear Medicine, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Frances Ware
- Department of Anesthesia, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Jan Wuth
- Department of Anesthesia, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Anne Bernadette Chang
- Queensland Children's Respiratory Centre and Children's Centre Health Research, Brisbane, Queensland, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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Tracheal cartilage growth by intratracheal injection of basic fibroblast growth factor. J Pediatr Surg 2017; 52:235-238. [PMID: 27887682 DOI: 10.1016/j.jpedsurg.2016.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 11/08/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE We have previously shown that intratracheal injection of slowly released (in gelatin) basic fibroblast growth factor (bFGF) significantly enlarged the tracheal lumen by a slight margin. This study aimed to investigate differences in tracheal cartilage growth by the intratracheal injection of bFGF doses in a rabbit model. METHODS Water (group 1; n=7; control) or 100μg (group 2; n=8) or 200μg (group 3; n=8) of bFGF dissolved in water was injected into the posterior wall of the cervical trachea of New Zealand white rabbits using a tracheoscope. All animals were sacrificed four weeks later. RESULTS The mean circumferences of cervical tracheas for groups 1, 2, and 3 were 18.8±0.83, 21.1±2.0, and 22.1±1.3mm, respectively. A significant difference was found between groups 1 and 2 (P=0.034) and groups 1 and 3 (P=0.004). The mean luminal areas of cervical tracheas for groups 1, 2, and 3 were 27.0±2.1, 32.2±4.8, and 36.3±4.6mm2, respectively. A significant difference was found between groups 1 and 3 (P=0.001). CONCLUSION Intratracheal injection of bFGF in the dose range used significantly promoted the growth of tracheal cartilage in a rabbit model. LEVELS OF EVIDENCE Level II at treatment study (animal experiment).
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Slow release of basic fibroblast growth factor (b-FGF) enhances mechanical properties of rat trachea. J Pediatr Surg 2015; 50:255-9. [PMID: 25638613 DOI: 10.1016/j.jpedsurg.2014.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 11/02/2014] [Indexed: 11/22/2022]
Abstract
AIM Severe tracheomalacia is a life-threatening disease, but symptoms usually improve with growth. The aims of this study were to investigate how slow release basic-Fibroblast Growth Factor (b-FGF) acts on tracheal cartilage, and whether growth-promoted trachea is more resistant against an increase in externally-applied pressure. METHODS Biodegradable gelatin hydrogel sheets soaked in 10 μl of distilled water (sham) or 0.5 or 5 μg/10 μl of b-FGF solution were inserted behind the cervical trachea of three-week-old male Wistar rats. The cervical trachea was harvested 4 weeks later. Extratracheal pressure was increased from 0 to 40 cmH2O in a chamber, while video-recording the internal lumen. The luminal area at each pressure was expressed as a proportion to that at 0 cmH2O. The amounts of collagen type II and glycosaminoglycan were measured by ELISA. RESULTS The luminal areas at 40 cmH2O in the control (no intervention), sham, and each of the b-FGF groups were 0.65, 0.62, 0.72, and 0.73, respectively. The amounts of collagen type II and glycosaminoglycan in each group were 127, 136, 193, 249 μg/mg, respectively, and 15, 16, 19, 33 μg/mg, respectively. There were significant differences between the control group and the FGF 5 group (P=0.02, 0.01, 0.01, for luminal area, collagen, and glycosaminoglycan, respectively). CONCLUSION 5 μg of slow-release b-FGF promotes matrix production (collagen type II and glycosaminoglycan). The growth-enhanced trachea was more resistant to collapse, suggesting that slowly released b-FGF might be useful in patients with severe tracheomalacia.
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Komura M, Komura H, Konishi K, Ishimaru T, Hoshi K, Takato T, Tabata Y, Iwanaka T. Promotion of tracheal cartilage growth by intra-tracheal injection of basic fibroblast growth factor (b-FGF). J Pediatr Surg 2014; 49:296-300. [PMID: 24528971 DOI: 10.1016/j.jpedsurg.2013.11.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/10/2013] [Indexed: 01/03/2023]
Abstract
PURPOSE Basic fibroblast growth factor (b-FGF) is a very effective growth factor that induces the proliferation of chondrocytes. This study aimed to investigate whether intra-tracheally-injected b-FGF solution promotes the growth of tracheal cartilage. METHODS Group 1: 500 μl of distilled water was injected at the posterior wall of the cervical trachea of New Zealand white rabbits by using a tracheoscope (n=5). Group 2: 100 μg/500 μl of b-FGF solution was injected at the posterior wall of the cervical trachea (n=5). Group 3: Biodegradable gelatin hydrogel microspheres incorporating 100 μg/500 μl of b-FGF solution were injected at the posterior wall of the cervical trachea (n=5). All animals were sacrificed 4 weeks later, and the outer diameter and luminal area of the cervical trachea at the site of b-FGF injection were measured. RESULTS The cervical tracheas in the two b-FGF injection groups were spindle-shaped and had a maximum diameter at the injection site. The median outer diameter of the cervical trachea in Groups 1, 2, and 3 was 7.3, 8.0, and 8.0mm, respectively, showing a significant difference among Groups 1, 2, and 3 (P=0.04). The median luminal area in Groups 1, 2, and 3 was 27.4, 29.4, and 32.1mm(2), respectively. The ad hoc test showed a marginally significant difference only between groups 1 and 3 (p=0.056). CONCLUSION Intra-tracheal injection of slowly released b-FGF enlarged the tracheal lumen.
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Affiliation(s)
- Makoto Komura
- Dept. of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655; Dept. of Pediatric Surgery, Graduate School of Medicine, Saitama Medical University, 38 Morohongo, Moroyamacho, Irumagun, Saitama prefecture 350-0495.
| | - Hiroko Komura
- Dept. of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655
| | - Kenichirou Konishi
- Dept. of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655
| | - Tetsuya Ishimaru
- Dept. of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655
| | - Kazuto Hoshi
- Dept. of Tissue Engineering, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655
| | - Tsuyoshi Takato
- Dept. of Tissue Engineering, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655
| | - Yasuhiko Tabata
- Dept. of Biomaterials, Field of Tissue Engineering, Institute of Frontier Medical Science, Kyoto University, 53 Shogoin Kawara cho, Sakyo-ku, Kyoto prefecture, 606-8507
| | - Tadashi Iwanaka
- Dept. of Pediatric Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655
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What's in a name? Expiratory tracheal narrowing in adults explained. Clin Radiol 2013; 68:1268-75. [DOI: 10.1016/j.crad.2013.06.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Revised: 06/21/2013] [Accepted: 06/26/2013] [Indexed: 10/26/2022]
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Abstract
Cough may be the first overt sign of disease of the airways or lungs when it represents more than a defense mechanism, and may by its persistence become a helpful pointer of potential disease for both patient and physician. On the other hand, impairment or absence of the coughing mechanism can be harmful and even fatal; this is why cough suppression is rarely indicated in childhood. Pediatricians are concerned more with the etiology of the cough and making the right diagnosis. Whereas chronic cough in adults has been universally defined as a cough that lasts more than 8 weeks, in childhood, different timing has been reported. Many reasons support defining a cough that lasts more than 4 weeks in preschool children as chronic, however; and this is particularly true when the cough is wet. During childhood, the respiratory tract and nervous system undergo a series of anatomical and physiological maturation processes that influence the cough reflex. In addition, immunological response undergoes developmental and memorial processes that make infection and congenital abnormalities the overwhelming causes of cough in preschool children. Cough in children should be treated on the basis of etiology, and there is no evidence in support of the use of medication for symptomatic cough relief or adopting empirical approaches. Most cases of chronic cough in preschool age are caused by protracted bacterial bronchitis, tracheobronchomalacia, foreign body aspiration, post-infectious cough or some combination of these. Other causes of chronic cough, such as bronchiectasis, asthma, gastroesophageal reflux, and upper respiratory syndrome appear to be less frequent in this age group. The prevalence of each depends on the population in consideration, the epidemiology of infectious diseases, socioeconomic aspects, and the local health system.
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Affiliation(s)
- Ahmad Kantar
- Pediatric Asthma and Cough Centre, Istituti Ospedalieri Bergamaschi, Bergamo, Italy.
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Trozzi M, Briganti V, Conforti A, Schiavino A, Bottero S. Resolution of opisthotonus in respiratory distress by aortopexy. Int J Pediatr Otorhinolaryngol 2013; 77:1372-3. [PMID: 23769450 DOI: 10.1016/j.ijporl.2013.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 05/18/2013] [Accepted: 05/21/2013] [Indexed: 11/26/2022]
Abstract
We report a case of worsening respiratory distress associated with opisthotonus secondary to tracheomalacia, a rather unique pathophysiological phenomenon. A 2-month-old male baby was referred to our hospital for respiratory distress syndrome with a noticeable opisthotonus. Examination and investigation confirmed the presence of an aberrant innominate artery compressing the trachea. The infant underwent aortopexy and made a dramatic post-operative recovery. Of special note, the opisthotonus vanished soon after the operation. Opisthotonus is not always related to neurological impairment and may be a warning sign of mediastinal overcrowding in patients with respiratory distress syndrome secondary to vascular compression.
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Affiliation(s)
- M Trozzi
- ENT Unit, Department of Surgery and Centre of Transplantation, Bambino Gesu Children's Hospital, Rome, Italy.
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Slow release of basic fibroblast growth factor (b-FGF) promotes growth of tracheal cartilage. J Pediatr Surg 2013; 48:288-92. [PMID: 23414853 DOI: 10.1016/j.jpedsurg.2012.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 11/12/2012] [Indexed: 01/08/2023]
Abstract
PURPOSE Tracheomalacia is a major cause of morbidity in conditions such as oesophageal atresia. However, symptoms usually improve with age. A more rapid growth of tracheal cartilage can be induced by basic-Fibroblast Growth Factor (b-FGF). This study aimed to investigate whether slow-release b-FGF could act as a novel treatment for tracheomalacia. METHODS Biodegradable gelatin hydrogel sheets incorporating 0.5, 5, or 50 μg/20 μl of b-FGF solution were inserted between the cervical trachea and esophagus of rats. No intervention was performed in rats in a control group. All animals were sacrificed 4 weeks later, and the luminal area of the cervical trachea and the thickness of the cartilage were measured. RESULTS The mean luminal areas in the control group and in the b-FGF groups were 3.1, 3.2, 3.8, and 2.6mm(2), respectively, and showed a peak area at 5 μg of b-FGF. A significant difference was seen only between the control group and the b-FGF 5 μg group (p<0.05). The mean thickness of the tracheal cartilage was 0.12, 0.13, 0.19, and 0.32 mm in the control and the b-FGF groups, respectively, and showed a dose-dependent increase, which was statistically significant between the b-FGF 5 μg or 50 μg groups and the control group (p<0.01). CONCLUSION This study showed that slow-release b-FGF enlarges the tracheal lumen and thickens the cartilage in a dose-dependent fashion.
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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). OBJECTIVES To evaluate the efficacy of medical and surgical therapies for children with intrinsic (primary) tracheomalacia. SEARCH METHODS The Cochrane Airways Group searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group's Specialised Register, MEDLINE and EMBASE databases. The Cochrane Airways Group performed the latest searches in March 2012. SELECTION CRITERIA All randomised controlled trials (RCTs) of therapies related to symptoms associated with primary or intrinsic tracheomalacia. DATA COLLECTION AND ANALYSIS Two reviewers extracted data from the included study independently and resolved disagreements by consensus. MAIN RESULTS We included one RCT that compared nebulised 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 analysed 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 nebulised 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 nebulised 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 nebulised 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.
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Affiliation(s)
- Vikas Goyal
- Queensland Children’s Medical Research Institute, The University of Queensland, Brisbane,
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Tracheobronchomalacia in children: review of diagnosis and definition. Pediatr Radiol 2012; 42:906-15; quiz 1027-8. [PMID: 22426568 DOI: 10.1007/s00247-012-2367-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 01/18/2012] [Accepted: 01/23/2012] [Indexed: 10/28/2022]
Abstract
Tracheobronchomalacia is characterised by excessive airway collapsibility due to weakness of airway walls and supporting cartilage. The standard definition requires reduction in cross-sectional area of at least 50% on expiration. However, there is a paucity of information regarding the normal range of central airway collapse among children of varying ages, ethnicities and genders, with and without coexisting pulmonary disease. Consequently, the threshold for pathological collapse is considered somewhat arbitrary. Available methods for assessing the airway dynamically--bronchoscopy, radiography, cine fluoroscopy, bronchography, CT and MR--have issues with reliability, the need for intubation, radiation dose and contrast administration. In addition, there are varying means of eliciting the diagnosis. Forced expiratory manoeuvres have been employed but can exaggerate normal physiological changes. Furthermore, radiographic evidence of tracheal compression does not necessarily translate into physiological or functional significance. Given that the criteria used to make the diagnosis of tracheobronchomalacia are poorly validated, further studies with larger patient samples are required to define the threshold for pathological airway collapse.
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Sanchez MO, Greer MC, Masters IB, Chang AB. A comparison of fluoroscopic airway screening with flexible bronchoscopy for diagnosing tracheomalacia. Pediatr Pulmonol 2012; 47:63-7. [PMID: 21830315 DOI: 10.1002/ppul.21517] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 06/16/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND Flexible bronchoscopy (FB) is the gold standard method of diagnosing tracheomalacia but it is not always feasible in settings with limited resources. Fluoroscopy is sometimes performed as an alternative diagnostic tool but there are no prospective studies that have evaluated the diagnostic accuracy of airway fluoroscopy for tracheomalacia using a-priori definitions. We determined the sensitivity, specificity, and likelihood predictive ratio of airway fluoroscopy compared with FB in children suspected of having an airway abnormality. METHODS Airway fluoroscopic examination was undertaken within 2-weeks of a FB in children aged <18-years and reported by a pediatric radiologist blinded to FB data. Fluoroscopic and FB methods and diagnostic criteria were standardized and defined a-priori. Tracheomalacia diagnosed by FB were independently scored (mild, moderate, severe) by 2 pulmonologists in a blinded manner. RESULTS In 22 children (median age 33 months, range 1-187) evaluated for airway abnormality, tracheomalacia was found in 21 children at bronchoscopy. Of these, fluoroscopy detected tracheomalacia in five children. Airway fluoroscopy was poorly sensitive (23.8%) but highly specific (100%), positive likelihood ratio was 8.6. However, in moderate-severe tracheomalacia, the sensitivity improved to 57.1% but the specificity reduced (93.3%). The agreement between bronchoscopists for tracheomalacia severity was excellent, weighted kappa 0.74 (95% CI 0.77, 0.98). CONCLUSION Airway fluoroscopy cannot replace FB which remains the tool for definitively diagnosing airway malacia. However, in absence of other modalities for diagnosis fluoroscopy should be considered in the setting of persistent respiratory symptoms compatible with the clinical picture of tracheomalacia.
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Affiliation(s)
- M O Sanchez
- Queensland Children's Respiratory Centre and Queensland Children's Medical Research Institute, Brisbane, Queensland, Australia.
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