[size=20px]A three-month old male is evaluated for expiratory stridor and cough. Bronchoscopy during spontaneous breathing demonstrates tracheal collapse of approximately 60%.

 

The most appropriate management of this infant with stridor is

 

A observation.

 

B continuous positive airway pressure.

 

C tracheostomy.

 

D aortopexy.

 

E internal tracheal stent.[/size]

D

(Untitled)

 

D

a

a

correct

 

In the majority of healthy and even premature infants primary tracheomalacia is a self limiting disease that infants will outgrow by two years of age as the tracheal cartilages stiffen. Supportive therapy is sufficient.

 

The normal intrathoracic trachea dilates during inspiration and narrows with expiration due to the difference between intraluminal and intrathoracic pressures. In tracheomalacia there is exaggeration of this normal physiologic process producing airway obstruction. It may be localized to one area of the trachea or involve the entire trachea and mainstem bronchi. Primary congenital tracheomalacia is more common in premature infants or those with an abnormal cartilaginous matrix such as mucopolysaccharidoses. The most common associated disease is esophageal atresia with tracheoesophageal fistula. In 75% of pathologic specimens from such infants the circumference of the tracheal cartilage is reduced and the membranous trachea widened accounting for easy collapsibility. Tracheomalacia may also be due to external tracheal compression associated with vascular rings or space occupying lesions.

 

Expiratory stridor and a barking cough are the most commonly reported symptoms although inspiratory stridor may be encountered if there is extrathoracic malacia. Symptoms are exacerbated by conditions which increase respiratory effort such as coughing, feeding or crying. Children with the most severe involvement may have acute life threatening events (ALTEs) or brief resolved unexplained event (BRUEs). A visible decrease of the tracheal diameter by over 50% is considered abnormal, but the majority of infants with tracheomalacia have over 75% collapse with dynamic complete occlusion in nearly one-third.

 

In children with life threatening events surgical intervention is warranted. Aortopexy is the procedure of choice for severe tracheomalacia. After removal or displacement of the intervening thymus, the ascending aorta is suspended ventrally to the sternum to elevate the attached anterior tracheal wall and reduce luminal collapse. This procedure can be performed either open or thoracoscopically. Intraoperative bronchoscopy is used to ensure accurate correction of the pathology. Continuous positive airway pressure may be used for temporary pneumatic stenting. Internal stenting or tracheostomy are reserved for treatment failures or extensive collapse.