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Tracheobronchial malacia and stenosis in children in intensive care: bronchograms help to predict oucome
1Paediatric Intensive Care Unit, Royal Children's Hospital, Parkville, Victoria 3052, Australia.
Insights
Contrast cinetracheobronchography and ventilation duration help predict outcomes for pediatric tracheobronchomalacia. Severe malacia or prolonged ventilation indicates a poor prognosis in critically ill children.
Area of Science:
- Pediatric Intensive Care Medicine
- Respiratory Medicine
- Diagnostic Imaging
Background:
- Severe tracheobronchial malacia and stenosis are significant causes of mortality in pediatric intensive care.
- Limited understanding exists regarding the diagnosis and prognosis of these conditions.
Purpose of the Study:
- To investigate the diagnostic utility of contrast cinetracheobronchography for tracheobronchomalacia and stenosis.
- To determine prognostic indicators for children with these airway conditions.
Main Methods:
- Retrospective study of 62 children diagnosed with tracheobronchomalacia or stenosis via contrast cinetracheobronchography (1986-1995).
- Analysis of patient records, focusing on diagnostic findings and clinical outcomes.
Main Results:
- Congenital heart disease was present in 74% of cases.
- Fifteen children had stenosis without malacia; 5 died.
- Twenty-eight of 47 children with malacia died; only 8 survived without sequelae.
- Specific bronchographic findings (moderate/severe main bronchus malacia, any severity bilateral main bronchus malacia, or any severity trachea/main bronchus malacia with prolonged ventilation) were highly predictive of mortality (p<0.00005).
Conclusions:
- Contrast cinetracheobronchography findings, coupled with ventilation duration, offer a valuable prognostic tool for pediatric tracheobronchomalacia.
- Bronchoscopy provided less useful prognostic information compared to cinetracheobronchography.
Background:
Severe tracheobronchial malacia and stenosis are important causes of morbidity and mortality in children in intensive care, but little is known about how best to diagnose these conditions or determine their prognosis.
Methods:
The records of all 62 children in whom one or both of these conditions had been diagnosed by contrast cinetracheobronchography in our intensive care unit in the period 1986-95 were studied.
Results:
Seventy four per cent of the 62 children had congenital heart disease; none was a preterm baby with airways disease associated with prolonged ventilation. Fifteen of the children had airway stenosis without malacia; three died because of the stenosis and two died from other causes. Twenty eight of the 47 children with malacia died; only eight children survived without developmental or respiratory handicap. All children needing ventilation for malacia for longer than 14 consecutive days died if their bronchogram showed moderate or severe malacia of either main bronchus (15 cases), or malacia of any severity of both bronchi (three additional cases); all children needing ventilation for malacia for longer than 21 consecutive days died if their bronchogram showed malacia of any severity of the trachea or a main bronchus (three additional cases). These findings were strongly associated with a fatal outcome (p<0.00005); they were present in 21 children (all of whom died) and absent in 26 (of whom seven died, six from non-respiratory causes). They had a positive predictive value for death of 100%, but the lower limit of the 95% confidence interval was 83.9% so up to 16% of patients meeting the criteria might survive.
Conclusion:
In this series the findings on contrast cinetracheobronchography combined with the duration of ventilation provided a useful guide to the prognosis of children with tracheobronchomalacia. The information provided by bronchoscopy was less useful.