Records of infants who were diagnosed as congenital tracheomalacia based on the flexible bronchoscopy between 2012 and 2015 at Kanchi Kamakoti CHILDS Trust Hospital, were reviewed. All the bronchoscopy procedures were video recorded with mutual verification by a fellow doctor trained in pediatric pulmonology. Except in two infants, all the bronchoscopy procedures were done under local anesthesia [3]. The observation of the anterior tracheal wall collapsing and reducing >50% of lumen diameter against the posterior wall was the basis of diagnosis of tracheomalacia. In addition to the bronchoscopic details, the spectrum of clinical presentation, associated radiographic and echocardio-gram findings were recorded.

Of the 88 infants (mean age 8 mo, 57 boys) with tracheomalacia diagnosed during the study period, 16 (18.2%) were born preterm, out of which five had received surfactant and ventilation for respiratory distress syndrome. Nineteen (21.6%) of infants were aged below 3 months, 20 (22.7%) were in the age group 4-6 months, 16 (18.2%) were aged between 7 and 9 months, and 33 (37.5%) were aged 10 months and above. The predominant complaints were wheeze in 51 (57.9%), stridor in 37 (42.1), and cough in 34 (38.6%) infants. All infants with tracheomalacia had recurrent respiratory problems requiring repeated nebulizations. Radiographic features included pneumonia (consolidation) in 26 (29.5%), collapse in 11 (12.5%), mild cardiomegaly in 2 (2.3%), hypoplasia of lung in 1 (1.2%); 48 (54.5%) had a normal chest X-ray. Bronchoscopy demonstrated malacia of the upper half of trachea in 37 (42.1%) and lower half in 51 (57.9%). Synchronized airway lesions were observed in 30 (34.1%) infants, which included laryngomalacia in 27 (30.7%) and bronchomalacia in 3 (3.4%). Congenital heart diseases were noted in 15 (17.0 %), which included atrial septal defect (4), ventricular septal defect (3), patent ductus artoriodus (3) pulmonary hypertension (2), partial anomalous pulmonary venous connection (1), single ventricle (1) and Fallot’s tetralogy (1). Twenty-one (23.8%) of infants with tracheomalacia required PICU care.

In this hospital record review, we documented that synchronized airway lesions and congenital heart diseases are found commonly in infants with tracheomalacia. The actual incidence of tracheomalacia cannot be arrived at as it was a hospital-based study. Earlier studies report on estimated incidence of at least 1 in 2,100 children [4]. Though some centers use general anesthesia and rigid bronchoscopes, we used flexible bronchoscopy under topical anesthesia. As tracheomalacia is a dynamic condition, flexible bronchoscopy performed under topical anesthesia is the preferred technique [5].

A recent study in infants with moderate and severe laryngomalacia, flexible bronchoscopy demonstrated synchronized lower airway anomalies in 48%, of which tracheomalacia was the most common [6]. Parenchymal lung lesions are also associated with tracheomalacia, and combined therapy to control pulmonary infection along with airway clearance (remove the backlog of secretions) may improve the outcome [7]. A high proportion of congenital heart disease in children with tracheonalacia has also been reported earlier [8-10], and it may be worthwhile screening all such children with echocardiography.

In our series, about one-fourth infants required ICU care for severe wheeze. In airway malacias, due to the defective cartilage, the contour of airways is maintained by the bronchial smooth muscle tone. When these children are treated with beta-agonists, their wheeze may worsen due to a further reduction in the muscle tone [11]. Thus any infant presenting with acute wheeze requiring a hospitalization whose response to treatment is inadequate or worsening with standard protocol warrants bronchoscopy to rule out underlying congenital airway anomalies.

The main limitations of this study are: retrospective data, referral bias, small sample size, and lack of follow-up data and surgical outcomes.

We conclude that infants with tracheomalacia have a high frequency of associated anomalies of airway and cardiovascular system.

Contributors: DV, KV: designing the study and analyzing the data. DV, SBS: drafted the manuscript; DV, SS: were involved in review of literature and manuscript preparation. The final manuscript was approved by all the authors.

Funding: None; Competing Interest: None stated.