Mini-Symposium: Esophageal Atresia and Tracheo-esophageal Fistula
Surgical Treatment of Tracheobronchomalacia: A novel approach

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Summary

Tracheobronchomalacia, as a whole, is likely misdiagnosed and underestimated as a cause of respiratory compromise in pediatric patients. Currently, there is no standardized approach for the overall evaluation of pediatric tracheobronchomalacia (TBM) and the concept of excessive dynamic airway collapse (EDAC); no grading score for the evaluation of severity; nor a standardized means to successfully approach TBM and EDAC. This paper describes our experience standardizing the approach to these complex patients whose backgrounds include different disease etiologies, as well as a variety of comorbid conditions. Preoperative and postoperative evaluation of patients with severe TBM and EDAC, as well as concurrent development of a prospective grading scale, has allowed us to ascertain correlation between surgery, symptoms, and effectiveness on particular tracheal-bronchial segments. Long-term, continued collection of patient characteristics, surgical technique, complications, and outcomes must be collected given the overall heterogeneity of this particular population.

Section snippets

INTRODUCTION

TBM and EDAC may coexist in patients with a combined pathological phenotype resulting in both acute and chronic respiratory illnesses. [1], [2], [3] Severe TBM has typically been characterized by coaptation of the airways with anterior and posterior collapse during exhalation in spontaneously breathing patients. [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13] In the pediatric population, both TBM and EDAC are often underdiagnosed in patients with airflow limitations and pediatric

Histopathological evaluation

Given the heterogeneity of populations with TBM and EDAC and the lack of knowledge regarding the overall prevalence of this disease, it is likely the numbers are underreported. The histopathological studies that have been performed postmortem have tended to group both TBM and EDAC together; however, they may represent different functional entities and represent both a dynamic component (EDAC) and a static component (TBM) and may also have associated concurrent problems with asthma and/or

MULTIDISCPLINARY TEAM

The impetus for development of the severity score for tracheobronchomalacia was to help provide a standard for communication amongst providers, guide surgeons and providers with a more precise description of the individual patient's anatomy, guide surgical planning, and assess postoperative results. The patients are best cared for under the aegis of a multidisciplinary team with expertise across all disciplines for this cadre of often complicated patients. Our multidisciplinary team consists of

Endoscopic Evaluation

Pre and post-operative bronchoscopies were performed and video recorded by the primary surgeons involved. Anatomic regions were evaluated in a standardized fashion. [18] In brief, the trachea was evaluated by anatomical region and severity of collapse. Anatomic regions were further classified into upper, middle, and lower trachea; and, right and left main stem bronchus. The patient was evaluated during gentle respiration along with vigorous active breathing following both diaphragmatic and

Surgical Technique

Primarily endoscopic exams and preoperative imaging guided the type of tracheobronchopexy performed and the surgeon determined the approach. Individualized surgical plans were based on the findings and expected results. Generally patients with associated esophageal disease underwent primary right posterior thoracotomy while those with cardiac disease underwent sternotomy. For those with multiple disease entities present, surgeons favored addressing all concerns during one operative case,

TREATMENT RESULTS AND POSTOPERATIVE EVALUATION

A representative sample of forty-eight patients were identified and treated at our institution over the past 3-year time-period. Thirty patients had concurrent pre-operative and post-operative bronchoscopies available with standardized scoring of all 6 regions of the trachea (T1, T2, T3, Carina, and Right and Left main stem Bronchi). Of the patients studied, 73% had an associated EA/TEF, 53% had CHD and 33% had both entities present. Median age at time of surgery was 8 months (range: 1-72

DISCUSSION

Overall, our current series of patients, who underwent direct anterior and/or posterior tracheobronchopexy for severe TBM with the development of a concurrent prospective grading scale to ascertain correlation between surgery, symptoms, and effectiveness on particular tracheal-bronchial segments, have done well. As there is currently no standardized grading score for pediatric TBM and EDAC, we recommend an overall grading score that incorporates symptoms with improvement given their surgical

CONCLUSIONS AND FUTURE STUDIES

A standardized approach, a novel grading scale, and a holistic team reduces the severity of TBM and EDAC. Clinical effectiveness was seen by the reduction of severity of symptoms as correlated to all segments of the airway. Our small series has shown that the use of direct tracheobronchopexy, or 2-stage operations for severe TBM and EDAC, has resulted in resolution of ALTEs and significantly reduced the incidence of recurrent pneumonias and use of supplemental oxygen. Given the heterogeneity of

EDUCATIONAL AIMS

The reader will be able to:

  • Describe the constellation of conditions associated with tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC)

  • Identify the differences seen in upper airway obstruction versus lower airway obstruction

  • Describe the adjunctive modalities utilized to determine the best surgical approach in a particular patient

  • Describe the various surgical therapies for tracheobronchomalacia with their associated advantages and disadvantages

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