A six months old male infant was admitted at our institution with history of repeated hospitalizations for wheeze and respiratory distress. Born as a term neonate by normal delivery, his neonatal period was uneventful. The infant developed first episode of wheeze at two months of life and was nebulized with salbutamol.

At three months of life, he was admitted for wheeze with respiratory distress and was treated as bronchiolitis for about a week. His chest skiagram at admission was reported normal. The infant used to have recurrent episodes of cough/wheeze for which he was treated by a nearby physician with oral bronchodilators and antibiotics.

At six months of age, he was readmitted at a pediatric care hospital for severe respiratory distress with wheeze. His blood counts were normal. The repeat skiagram and CT scan of the chest showed hyperaeration of the left lung with consolidation of the right upper lobe. Since the wheeze persisted despite repeated beta agonist nebulizations and imaging showed obstructive hyperaeration of the left lung, rigid bronchoscopy was performed to rule out foreign body aspiration. No intraluminal pathology was identified. Following this, the child was referred to us.

On admission, the infant was dyspneic with bilateral wheeze and decreased air entry on the left side. The upper GI barium study and echocardiography were within normal limits. Fibreoptic bronchoscopy under local anesthesia with video monitoring demonstrated dynamic compression of the trachea at the lower one-third, which was exagge-rated during expiration consistent with moderate tracheo-malacia. A similar finding at the orifice of the left main bronchus suggesting bronchomalacia was observed and the diagnosis of tracheobronchomalacia left side was made.

The diagnosis of airway malacias presents a clinical challenge because of the frequent overlap of symptoms with more common childhood respiratory illnesses like asthma [1]. Fibreoptic bronchoscopy done under local anesthesia is the gold standard for the diagnosis of dynamic airway lesions [2].

Dynamic compression of the left main bronchus had presented as obstructive hyperaeration during the third episode of wheeze. It has been documented that severe bronchomalacia of the main bronchus acts as ball valve and produces hyperaeration of lung (obstructive emphysema) [3]. Impaired drainage of secretions caused by airway malacia results in backlog of secretions which may be responsible for the consolidation of the right upper lobe [4].

In airway malacias the contour of airways is maintained by the bronchial smooth muscle tone [5]. Infants with congenital airway malacias, presenting with wheeze may not improve with beta agonist nebulisation because in such lesions, beta agonists by reducing the muscle tone can aggravate the pathology. The child’s improvement of respiratory problems with discontinuing of beta-agonist and continuation of semisynthetic anticholinergics (ipratropium) nebulization substantiates this. Though surgical interventions like aortopexy may be required in severe cases, majority of milder forms of airway malacias invariably improve with regular chest physiotherapy and postural drainage [1].

This case highlights the important principle that young infants presenting with recurrent wheeze and respiratory distress with poor response to bronchodilators may be advised flexible bronchoscopy as the initial investigation of choice for early diagnosis and effective management of airway malacias.

Contributors: DV has conceptualized the study and contributed to writing the manuscript. SK was involved in data analysis, outcome assessment, literature review and writing the manuscript. VEV was involved in critical analysis of the manuscript.

Funding: None.

Competing interests: None stated.

1. Carden KA. Tracheomalacia and tracheobronchomalacia in children and adults–an in-depth review. Chest. 2005;127:984-1005.

2. Austin J, Ali T. Tracheomalacia and bronchomalacia in children: Pathophysiology, assessment, treatment and anesthesia management. Pediatr Anesth. 2003;13:3-11.

3. Mayer S, Laura N, Gerald Z, Joseph A. Pediatric intrathoracic large airway obstruction: Diagnostic and therapeutic considerations. Pediatric Emergency Care. 1994;10:313-2.

4. Yalç1n E, Do ru D, Özçelik U, Kiper N. Airway malacia disorders in children. Chest. 2006;130:304.