Management of Laryngotracheomalacia
Most cases of laryngotracheomalacia should be managed conservatively with observation alone, as approximately 90% of patients improve with time as the airway cartilage matures, typically resolving spontaneously by age 2-3 years. 1
Diagnostic Evaluation
- Flexible bronchoscopy is the gold standard for diagnosis and should be performed in infants with persistent wheezing despite treatment with bronchodilators and corticosteroids 1
- CT chest with IV contrast can be useful for initial imaging to assess location, shape, and dimensions of the affected area 1
- Bronchoscopy should be performed with spontaneous respiration, as tracheomalacia can be underestimated during static assessment in deeply anesthetized patients 2
Management Algorithm
Step 1: Assess Severity
- Mild to moderate symptoms (intermittent stridor, occasional wheezing):
- Conservative management
- Severe symptoms (life-threatening airway obstruction, respiratory failure, recurrent pneumonias, failure to thrive):
- Consider interventional approaches
Step 2: Conservative Management
- Positioning therapy - elevate head of bed, prone positioning 1
- Treat concurrent conditions that may exacerbate symptoms:
- Gastroesophageal reflux
- Respiratory infections
- Allergies 1
- Medication considerations:
- Racemic epinephrine for temporary relief during acute exacerbations
- Systemic corticosteroids to reduce airway edema during exacerbations
- Caution: Avoid bronchodilators in some cases as they may worsen dynamic airway collapse by relaxing central airway smooth muscle 1
Step 3: For Moderate to Severe Cases
- Continuous Positive Airway Pressure (CPAP) can provide distending pressure to stent open collapsible airways 1
- Multiple case series and reports show CPAP immediately decreases respiratory distress, restores airway patency, and improves pulmonary function 2
- Can be used as bridge therapy while awaiting spontaneous improvement
Step 4: For Severe Cases Not Responding to Conservative Measures
- Surgical options:
- Supraglottoplasty for laryngomalacia - endoscopic removal of flaccid supraglottic tissue 3, 4
- Aortopexy for tracheomalacia - highly effective for isolated tracheomalacia (100% success rate) but less effective for tracheobronchomalacia (25% success rate) 2, 1
- Tracheostomy - only when other means of correcting obstruction have been ruled out 1
- Stenting - expandable intraluminal metallic stents for specific cases 1
Special Considerations
Anesthesia Management
- Consider deep extubation techniques for uncomplicated airways
- LMA exchange in "at-risk" extubation
- Prepare for difficult airway management 1
Complications to Monitor
- Airway stenting complications:
- Formation of granulation tissue
- Stent migration
- Erosion 1
- Post-tracheostomy issues:
- Delayed speech development
- Need for specialized care and monitoring 1
Prognosis
- Most cases (90%) improve with time alone 2, 1
- Regular follow-up is essential to monitor:
- Respiratory status
- Growth and development
- Need for intervention adjustment 1
Pitfalls to Avoid
- Performing unnecessary tracheostomy when conservative management would suffice
- Using bronchodilators in cases where they may worsen dynamic airway collapse
- Failing to assess the entire airway, as tracheomalacia often coexists with other airway anomalies
- Underestimating tracheomalacia during static assessment under deep anesthesia
- Using excessive negative pressure during suctioning (should not exceed 50-80 cm H2O) as this increases likelihood of mucosal damage 2
By following this management approach, most patients with laryngotracheomalacia can be effectively treated with minimal intervention, reserving more invasive procedures for those with severe symptoms that don't respond to conservative measures.