Tracheobronchomalacia: Does One Size Fit All?
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Tracheobronchomalacia
Tracheomalacia
Pulmonologists
Descending aorta
Summary 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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Tracheomalacia
Malacia
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Auscultation
Laryngomalacia
Tracheobronchomalacia
Right Main Bronchus
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Tracheomalacia is an unfrequent disease that causes tracheal collapse during breathing. It is generally associated to esophageal atresia, but cases of primary tracheomalacia and others secondary to extrinsic compression, have also been described. Spontaneous resolution is generally the rule and only a few cases need surgical treatment. When this therapy fails or is not indicated for any reason, endoluminal tracheobronchial stents may be used. We have treated two patients with four expandable metallic stents: one had severe tracheomalacia associated to esophageal atresia and the other tracheobronchomalacia secondary to cardiomegaly. Results have been good in both cases.
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To evaluate the use of a non-breath held 3D-CT-bronchoscopy in detecting tracheobronchomalacia in infants.The study was based on 17 infants who received both bronchoscopy and 3D-CT-bronchoscopy within 1 week at our institution. 3D-CT-bronchoscopy consisted of an axial-enhanced-chest-scan and a 3D-volume-external rendering (VR) image of the airways and was scanned with a consciously sedated non-breath held protocol, using a 64-channel-multidetecter-CT scanner. VR images were classified by two radiologists as normal, luminal narrowing or complete obliteration. All patients were confirmed with bronchoscopy and the sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) was calculated.Ten (M:F¼7:3, mean 1 month) out of 17 infants were confirmed of tracheobronchomalacia. The sensitivity was <75% in detecting laryngomalacia, tracheomalacia and bronchomalacia. However, the specificity and NPV were higher than 75% for laryngomalacia, tracheomalacia and bronchomalacia and the PPV was 100% in laryngomalacia and tracheomalacia. False-positive cases included secretion plugging, extrinsic compression and foreign body, which were distinguishable in axial scans. The effective radiation dose was 0.73_0.49mSv.A volume rendering image of the airways can be used to evaluate tracheobronchomalacia and stenosis in infants. Although, non-breath held MDCT is not recommended for screening airway lesions, narrowing of the larynx, and trachea and patency of the bronchus are reliable findings.
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Tracheobronchomalacia, defined as variable collapse of the airways, has been recognized as an important cause of respiratory morbidity but still widely underdiagnosed. Bronchoscopy is still considered as the gold standard, but numerous limitations are known, especially for fragile sick children. Moreover, information on parenchymal lung disease cannot be described. There is a real need for a reliable, non-invasive test to help detection of airway and parenchymal malformations in children, specifically when bronchoscopy cannot be performed.34 paediatric patients underwent cine multidector CT for ongoing respiratory symptoms and were included. All CT images were of good quality and sedation was never needed. Airway disease such as trachea-broncomalacia with/without stenosis was described in 53% with the first being more frequent. Bronchomalacia alone was described in 10 patients and in 4 patients was associated with tracheomalacia. Moreover, CT allowed identification of parenchymal disease in 10 patients. Airways stenosis alone was detected in seven patients. The majority of patients (85%) underwent also bronchoscopy for clinical decision. The agreement between CT and bronchoscopy was explored. The two examinations did not agree only in two cases. CT dynamic showed an excellent sensitivity of 100% (81.47-100 %), a great specificity of 82% (48.22-97.72 %), NPV 100%, and PPV 90% (72-96.9 %).Dynamic CT results an effective and highly sensitive diagnostic exam for children with tracheo-bronchomalacia. CT is especially indicated for those small and fragile patients that cannot undergo an invasive investigation. Moreover, CT allows a detailed evaluation both of the airways and the lungs which is useful for the clinical management.
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Objectives To explore the role of flexible bronchoscopy in diagnosing tracheobronchomalacia in chil -dren. Methods Clinical data and flexible bronchoscopy of 335 children with persistent wheezing or intractable cough from December 2002 to June 2006 were retrospectively analyzed. Results Tracheobronchomalacia was diagnosed in 62 out of a total of 335 patients, in which 17 cases were tracheomalacia, 27 cases were tracheobronchomalacia and 18 cases were bronchomalacia. Primary tracheobronchomalacia was identified in 59 cases while the other 3 were secondary tracheobronchomalacia characterized with extrinsic compression of the trachea. Of the 62 patients, 7 were laryngomalacia, 53 tra-cheosteosis. Fifty-two (52) of the 62 had been mistakenly diagnosed as infantile asthma, reactive airway disease before flexible bronchoscopy. Conclusions Tracheobronchomalacia is one of the reasons causing wheezing or chronic cough in children. Flexible bronchoscopy can be regarded as a golden criteria for diagnosis of tracheobronchomalacia.
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Down syndrome is a common chromosomal abnormality associated with many different structural anomalies. Tracheomalacia results in tracheal collapse when increased airflow is demanded due to the flaccidity of the tracheal support cartilage. Sufficient research and data are currently not available on airway malformations associated with Down syndrome, including tracheomalacia. In this case report, we discuss a Down syndrome patient with pneumonia found to have narrowing of his airway which resulted in prolonged hospital stay and difficulty in management. In most children with Down syndrome, tracheomalacia, tracheobronchomalacia, and bronchomalacia are all under diagnosed, yet these anomalies are more commonly missed in adults with Down syndrome. This can result from the patient’s presentation, which tends to be non-specific, and unless a specific obstruction is considered, it is unlikely that such forms of narrowing will be discovered. Severe adult tracheomalacia is a severe condition that can be difficult to treat, especially when associated with an airway infection that may result in increased mortality rates. J Med Cases. 2015;6(10):460-462 doi: https://doi.org/10.14740/jmc2287w
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The study was aimed to identify the role of virtual bronchoscopy in detection of airway malacia in children. In a pre-experimental study over 3 years (from Nov. 2003 to Oct. 2006), 35 consecutive patients were presented to Tabriz Children's Hospital with clinical manifestations of airway malacia, examined by the technique of virtual bronchoscopy. Thirty five patients including 23 males and 12 females with the mean age of 3.7 +/- 1.6 months were studied. The presence of airway malacia and its location and severity were determined by virtual bronchoscopy in all studied cases; that revealed: laryngomalacia, bronchomalacia, tracheomalacia, laryngotracheomalacia and laryngobronchomalacia in 42.8, 25.7, 20, 8.6 and 2.9% of patients, respectively. Virtual bronchoscopy is a non-invasive, accurate and rapid imaging technique with an excellent validity for diagnosis of airway malacia and stenosis, therefore it can replace conventional bronchoscopy.
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