Download Tracheomalacia

Tracheomalacia
R3 吳俊璟
Weakness of trachea
Reduction of the longitudinal elastic
fibers of the pars menbranacea
™ Impaired cartilage integrity, flaccidity
of the supporting tracheal cartilage
™ Reduced anterior-posterior airway
caliber
™ Histopathologic characteristics
™
Z The
membranous trachea: larger
Z The ration of cartilage to muscle:
reduced
Major airway collapse classification
Type
Presentation
Type I
Congenital or intrinsic tracheal abnormalities that can
be associated with a tracheoesophageal fistula
Type II
Extrinsic defects or anomalies, such as a vascular
ring causing undue pressure on the trachea
Acquired tracheomalacia that occurs with prolonged
Type III
intubation or chronic tracheal infections
Pediatric tracheomalacia
™
Congenital TM
Z most common congenital
anomaly of the trachea,
more in premature
Z Most common associated
disease Æ
tracheoesophageal fistulaÆ
faulty division of the foregut
into the trachea and
esophagus
Z Primary TM is a self limiting
disease
Pediatric tracheomalacia
™
Acquired TM
Z More
common
Z Male predominance
™
Associated conditions
Z Cardiovascular:
20~58%
Z Bronchopulmonary: 52%
Z GE reflex: 50~78%
Z Neurologic impairment
Z Development delay
Incidence and nature history
™ 1/1445
infants
™ 30% in children ≤ 3 y/o undergoing
bronchoscopy for respiratory distress.
™ Primary TM is a self limiting disease
™ Infants outgrow the condition by 2 y/o
™ The mortality rate from severe TMÆ80%
Symptoms
Mild: respiratory
difficulties associated
with infectious process
™ Moderate: stridor,
wheezing, recurrent
infection and cyanosis
™ Severe: marked
sputum retention,
reflex apnea and
cardiac arrest
™
Diagnosis (I)
™
™
History and physical
examination
Radiography:
Z Sensitivity:62%
Z Inspiratory and expiratory
views
Z Airway Fluoroscopy
Z Barium Swallow
™
Bronchoscopy
Z General anesthesia
Z Decrease 50% diameter
Diagnosis (II)
™
CT scan
Z High sensitivity
Z Dynamic CT
Z Multidetector helical CT
Z Virtual bronchoscopy
™
MRI scan
Z Evaluate
extrinsic
compression
Z Vascular compression
syndromes
Treatment (I)
™ Conservative
therapy
ZTreat respiratory infection
ZHumidified oxygen therapy
ZPulmonary physiotherapy
™ Tracheostomy
and mechanical ventilation
Z12%~62%
ZElongated tracheostomy tube
™ Continuous
positive airway pressure (CPAP)
Treatment (II)
™
Surgery
Z Indication:
recurrent
pneumonia, intermittent
respiratory obstruction,
inability to extube the
airway, dying spell
Z Aortopexy
Z External splinting with
autologous and
prosthetic materials
Treatment (III)-internal tracheal stent
™
Silicone prothesis
Z Montgomery,1965
Z Granulation
Z Easy to remove
™
Metal stent
Z Minimal thickness
Z Easy deployment
Z Granulation
Z Migration
Z Difficult removal
Z Halitosis
Adult TM
Isolated tracheal enlargement, Mounier-Kuhn,
1932
™ Acquired tracheal enlargement, Lemoine, 1949
™ Classification by macroscopic finding:
™
Z Lateral
wall narrowÆ saber-sheath type, fissure shape
Z Anterioposterior wall narrowÆ crescent type, scabbard
shape
Z Circumferential narrowing, combination type
Classification of adult tracheomalacia
™
Primary (congenital)
Z Polychondritis
Z Idiopathic (Mounier-Kuhn
™
syndrome)
Secondary (acquired)
Z Posttraumatic
(postintubation, posttracheotomy,
external chest trauma, post-lung transplantation)
Z Emphysema
Z Chronic bronchitis
Z Chronic inflammation (relapsing polychondritis)
Z Chronic external compression of trachea (malignancy,
benign tumors, cysts, abscesses, aortic aneurysm)
Z Vascular rings (diagnosed in childhood)
Incidence and symptoms
™ Majority
of adult TMÆ acquired, in men > 40
y/o
™ 1% in patient with respiratory disease for
bronchoscope.
™ TM is progressive in some patient
™ Symptoms: asymptomatic until infection,
dyspnea, cough, sputum production,
hemoptysis, wheezing, stridor, syncope
Diagnosis
™
Bronchoscope:
Z Mild:50~75%
Z Moderate:>75%
Z Severe: posterior wall
touches the anterior wall
™
™
™
CT
MRI
Pulmonary function study
Z not diagnostic
Z Decreased FEV1, low peak
flow rate with repeat
decrease in flow
Treatment
™
™
™
™
Supportive, treat underlying disease
CPAP
Tracheostomy
Stent
Z Metal: flexible bronchoscope,
Z Silicone: rigid bronchoscope, GA
Z External stenting
™
Surgery
Z Surgical supportÎ bone graft to posterior wall
Z Resection and reconstruction
Z Surgical placation of posterior wall with mesh
References
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Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing,
and dyspnea are not asthma. Pediatrics. 2007 Oct;120(4):855-64.
Agarwal A, Mishra AK, Gupta SK, Arshad F, Agarwal A, Tripathi M,
Singh PK. High incidence of tracheomalacia in longstanding goiters:
experience from an endemic goiter region. World J Surg. 2007
Apr;31(4):832-7.
Epstein SK.Late complications of tracheostomy. Respir Care. 2005
Apr;50(4):542-9.
Carden KA, Boiselle PM, Waltz DA, Ernst A. Tracheomalacia and
tracheobronchomalacia in children and adults: an in-depth review.
Chest. 2005 Mar;127(3):984-1005.
Adliff M, Ngato D, Keshavjee S, Brenaman S, Granton JT. Treatment
of diffuse tracheomalacia secondary to relapsing polychondritis with
continuous positive airway pressure.Chest. 1997 Dec;112(6):1701-4.
Aquino SL, Shepard JA, Ginns LC, Moore RH, Halpern E, Grillo HC,
McLoud TC. Acquired tracheomalacia: detection by expiratory CT scan.
J Comput Assist Tomogr. 2001 May-Jun;25(3):394-9
References
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Madden BP, Loke TK, Sheth AC.Do expandable metallic airway stents
have a role in the management of patients with benign
tracheobronchial disease? Ann Thorac Surg. 2006 Jul;82(1):274-8
Isa AY, Macandie C, Irvine BW. Nitinol stents in the treatment of
benign proximal tracheal stenosis or tracheomalacia. J Laryngol Otol.
2006 Jan;120(1):32-7.
Masters IB, Chang AB, Patterson L, Wainwright C, Buntain H, Dean
BW, Francis PW. Series of laryngomalacia, tracheomalacia, and
bronchomalacia disorders and their associations with other conditions
in children. Pediatr Pulmonol. 2002 Sep;34(3):189-95
McNamara VM, Crabbe DC.Tracheomalacia. Paediatr Respir Rev.
2004 Jun;5(2):147-54.
Göbel G, Karaiskaki N, Gerlinger I, Mann WJ. Tracheal ceramic rings
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Oct;117(10):1741-4.