The role of the pediatrician in caring for children with tracheobronchomalacia

ABSTRACT

Introduction

Children with tracheobronchomalacia (TBM) experience excessive dynamic collapse of the central airway(s). TBM remains an under-diagnosed condition, and there is on ongoing need to raise awareness amongst pediatricians.

Areas covered

The literature from PubMed, MEDLINE, EMBASE and Cochrane Controlled Trials Register electronic databases was searched from 1 January 1980 to 14 January 2020. Eligible studies relating to the diagnosis, investigation and management of tracheobronchomalacia in children were included. In this review, we highlight the clinical symptoms of TBM such as the typical barking cough, wheezing, recurrent lower respiratory tract infections or acute life-threatening events. These symptoms worsen when the child is making increased respiratory efforts, such as during crying, coughing and during intercurrent infective illness. This article focuses on the role of the pediatrician in recognizing the condition, the investigative process, and the medical management based on the clinical severity. The principle of management should be holistic, tackling the medical issues of TBM and associated comorbidities, as providing support to families.

Expert opinion

There remains a need to devise objective and reproducible bronchoscopic and radiological definitions of severity of TBM. Further studies looking at long-term outcomes of medical therapies used in TBM are required.

KEYWORDS:

• Acute life-threatening events
• airway obstruction
• anticholinergic
• bronchomalacia
• beta agonists
• chest physiotherapy
• infantile wheeze
• mucoactive agents
• recurrent pneumonias
• tracheomalacia

Article highlights

• Pediatricians need to be cognisant of the various presentations of tracheobronchomalacia (TBM), including troublesome cough, persistent wheeze, recurrent pneumonia and acute life-threatening episodes, and refer (or undertake in a multidisciplinary context) appropriate diagnostic investigations.

• The current gold standard of diagnosis of TBM, and grading of its severity, is by flexible bronchoscopy undertaken with spontaneous breathing.

• Management plans depend on the clinical course and severity of the TBM. Medical therapies including bronchodilators and antibiotics have limited evidence to support their use.

• The pediatrician should be able to recognise and manage co-morbidities such as gastro-oesophageal reflux (GOR) disease and eosinophilic oesophagitis.

• Providing empathetic and supportive care to children with TBM and their families is pivotal to the management.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.