Pediatric tracheobronchomalacia and major airway collapse

Based on histopathologic, endoscopic, and clinical findings of the flaccid airway, new descriptive terms--major airway collapse types 1 through 3--are proposed to better define tracheobronchomalacia. A typing and grading system is offered to objectively analyze and compare clinical cases. Endoscopic and anesthetic techniques are presented for use in children with respiratory distress suggestive of tracheobronchomalacia. Spontaneous ventilation with laryngoscopic insufflation of anesthetic gases and the use of small-diameter telescopes without bronchoscopes are key elements for the examination of the dynamic pediatric airway. Pitfalls of classic bronchoscopy techniques are described that can lead to a missed diagnosis. Between 1987 and 1990, over 200 telescopic bronchoscopies were performed at Wilford Hall US Air Force Medical Center on 129 children 3 years old and younger with respiratory distress. By means of the described techniques, 38 children (30%) with major airway collapse were identified. Major airway collapse was associated with a variety of endoscopic and cardiac abnormalities. With the emergence of sophisticated neonatal pediatric respiratory care, a growing number of premature infants with major airway collapse are surviving. Early, precise endoscopic diagnosis allows optimal management.