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CASE REPORT
Year : 2019  |  Volume : 22  |  Issue : 10  |  Page : 1459-1461

The use of expandable metallic airway stent in a baby with tracheomalacia: A case report


1 Department of Thoracic Surgery, Gaziantep University, Gaziantep, Turkey
2 Department of Thoracic Surgery Clinics, Gaziantep Medical Park Hospital, Gaziantep, Turkey

Date of Acceptance04-Jun-2019
Date of Web Publication14-Oct-2019

Correspondence Address:
Dr. A Ulusan
Department of Thorax Surgery, Gaziantep University, Gaziantep; Gaziantep Üniversitesi Kampus Alanı, Tıp Fakültesi Dekanlığı, Şehitkamil, Gaziantep - 27310
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_595_18

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   Abstract 


Tracheobronchomalacia is a rare condition in the pediatric age group which may be life-threatening when it occurs. The common form of tracheomalacia is congenital, presenting with wheezing and cough. We report a case of a 65-day-old baby who was treated with non-invasive mechanical ventilation due to respiratory distress since the day of birth. Tracheomalacia was diagnosed based on the physical examination and the thorax computerized tomography (CT) findings. Patient was initially treated with noninvasive positive pressure ventilation and thereafter, fitted with a tracheobronchial conical fully-covered self-expandable nitinol stent. After stent insertion and the respiratory situation of the patient improved, ventilatory weaning and extubation were possible. A careful selection of suitable patients, appropriate stent type and the site, where it has to be placed is mandatory for successful airway stenting. Also, children must be adequately followed-up to prevent the possible life-threatening complications after stent insertion.

Keywords: Airway stenting, bronchoscopic treatment, self-expandable metallic stent, tracheomalacia


How to cite this article:
Ulusan A, Elbeyli L. The use of expandable metallic airway stent in a baby with tracheomalacia: A case report. Niger J Clin Pract 2019;22:1459-61

How to cite this URL:
Ulusan A, Elbeyli L. The use of expandable metallic airway stent in a baby with tracheomalacia: A case report. Niger J Clin Pract [serial online] 2019 [cited 2019 Nov 15];22:1459-61. Available from: http://www.njcponline.com/text.asp?2019/22/10/1459/269023




   Introduction Top


Tracheobronchomalacia (TBM) is a rare condition in the pediatric age group with an incidence of 1:2100, but associated with significant morbidity and mortality.[1] It may be congenital or acquired. The congenital TBM is one of the most frequent causes of tracheobronchial obstruction in childhood.[1] In this disorder, the tracheal wall is abnormally soft and postero-anterior collapse occurs during expiration. Segmental tracheomalacia (TM) is the most frequent type of TBM. In the pediatric population, the TBM improves and often resolves with the growth of the child. For that reason and because of the complexity of surgical procedures with the potential for serious complications, only patients with severe life threatening TBM are treated invasively.

Management varies from a conservative approach to complex surgical procedures depending on the clinical condition of the patient and the type and severity of the disease. In 1995, Filler et al. first reported the bronchoscopic treatment of airway obstruction with metallic stents [1]. Since then, some researchers have published their experiences with the effects of stenting in airway obstruction.[2],[3],[4] In this study, we report a baby with tracheomalacia who was treated with a tracheobronchial conical fully covered self-expandable nitinol stent.


   Case Report Top


We received permission from the parents of the patient for this case report. The patient was 65 days at the time of receiving the treatment. He was born at 28 week gestation by cesarean delivery and weighed 1400 g at birth. He is the first child of the family. He had become dependent on mechanical ventilation due to respiratory distress since the day of birth. The patient was diagnosed of tracheomalacia based on the findings of stridor, hoarseness, aphonia and feeding difficulties on physical examination and the airway segment starting from the mid-trachea and extending to the carina and then the main bronchi, showing stenosis in mid-trachea on the thorax computerized tomography (CT) findings [Figure 1]a, [Figure 1]b, [Figure 1]c. There was no history of consanguineous marriage. No other family member had history of tracheomalacia. Bronchoscopy was done with a rigid bronchoscope of 5f internal diameter (Catalog no. 10308 B, Tuttlingen, Germany). Tracheomalacia was detected in the middle segment of the trachea [Figure 1]d. The clinical indication was carefully determined before stent placement. The patient was fitted with a tracheobronchial conical fully-covered self-expandable nitinol stent (Tracheobronxane Silmet ®, Novatech SA, France), which was 2 cm long and 6 mm diameter. The stent was 2 cm from the vocal cord and 0.5 cm from the carina [Figure 1]e.
Figure 1: (a-c) Thoracic computed tomography: the airway segment starting from the mid-trachea and extending to the carina and then the main bronchi, showing stenosis in mid-trachea. d-e. Pictures of the trachea during the rigid bronchoscopy procedure. (d) Increased transverse diameter and severe malacia in trachea before stent placement (e) Improvement of the tracheal lumen after stent placement. (f) Chest radiograph of the patient showing stent one week after placement

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The respiration of the patient improved dramatically after stent insertion. There wasn't any life-threatening complication (bleeding, laceration, asphyxia etc.) after stent insertion. Ventilatory weaning and extubation were possible 24 hours after. [Figure 1]f shows the chest radiograph of the patient one week after stent placement. He could breathe independently although still under observation in the incubator because of prematurity and very low birth weight.


   Discussion Top


Airway malacia may be primary as in the case reported or secondary to other anomalies such as esophageal atresia (EA) with tracheoesophageal fistula (TEF), vascular rings, or mediastinal masses. The accumulation of metabolic products as in mucopolysaccharide storage disorders can rarely cause malacia.[5]

Segmental tracheomalacia (TM) is the most frequent type and was portrayed in the index patient who had TM at the mid-trachea. The entire tracheae or even the bronchi can however be affected in some patients.[5]

The main indications for airway stent placement are TBM and airway stenosis such as congenital tracheal stenosis (CTS), acquired tracheal stenosis (ATS), and very rarely tracheal stenosis due to malignant tumors invading or compressing the airway. Also, stenting has been widely used as a complementary measure after airway surgery. In that case, the aim is to keep the trachea or bronchi patent during the healing period.[5]

Airway stenting in the pediatric population is a relatively recent technique and since 1980, only a small number of cases have been published.[3] Severe and even lethal stent-related complications (bleeding, laceration etc.) in children who undergo airway stenting are often attributable to performing the procedure in children who not clinically stable and were too sick for other interventions.

Patients with mild-to-moderate respiratory symptoms do not require intervention because the pathology improves and spontaneous recovery frequently occurs with the growth of the child, usually by the 2nd or 3rd year of life. Children who have become dependent on mechanical ventilation and cannot be extubated like our patient are suitable for surgical or endoscopic intervention. Also, children showing severe symptoms such as apneic episodes, cyanosis, or recurrent pulmonary infections, are candidates for surgical or endoscopic intervention.[6]

A few studies have demonstrated the applicability of stenting as a therapeutic preference for severe TBM in children.[3],[5] Serio et al.[3] suggested that stent placement be used as conservative treatment only when other medical treatments have failed, and in case of persisting malacia/stenosis with difficulty in weaning off mechanical ventilation, or persistent respiratory distress after the surgical correction like in our patient.[3] It was also suggested that the procedure be considered before considering more invasive surgical options, such as tracheostomy or tracheoplasty.[3] Furthermore, Anto'n-Pacheco et al. reported that the criteria for airway stenting are the failure to wean from ventilation, severe respiratory distress, failure of surgical treatment, bronchomalacia, and tracheomalacia refractory to previous tracheostomy.[2] Our patient satisfied these conditions and therefore benefitted from stent placement.

The present study has some limitations. It is an observational study of a single case and there was no control group to compare stent intervention against other treatment modalities. Long-term prospective multicenter studies are needed to evidently define clinical indications for airway stenting in children.

In conclusion, airway stenting represents a conservative treatment for tracheomalacia before more invasive surgical techniques and can be very efficient in carefully chosen cases. A careful selection of suitable patients, the appropriate stent type and the site where it has to be placed are mandatory for successful airway stenting. Also, children must be followed-up adequately to prevent the possible life-threatening (bleeding, laceration, asphyxia etc.) complications after stent insertion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Filler RM, Forte V, Fraga JC, Matute J. The use of expandable metallic airway stents for tracheobronchial obstruction in children. J Pediatr Surg 1995;30:1050-5; discussion 5-6.  Back to cited text no. 1
    
2.
Anton-Pacheco JL, Cabezali D, Tejedor R, López M, Luna C, Comas JV, et al. The role of airway stenting in pediatric tracheobronchial obstruction. Eur J Cardiothorac Surg 2008;33:1069-75.  Back to cited text no. 2
    
3.
Serio P, Fainardi V, Leone R, Baggi R, Grisotto L, Biggeri A, et al. Tracheobronchial obstruction: Follow-up study of 100 children treated with airway stenting. Eur J Cardiothorac Surg 2014;45:e100-9.  Back to cited text no. 3
    
4.
Nicolai T, Huber RM, Reiter K, Merkenschlager A, Hautmann H, Mantel K. Metal airway stent implantation in children: Follow-up of seven children. Pediatr Pulmonol 2001;31:289-96.  Back to cited text no. 4
    
5.
Anton-Pacheco JL. Tracheobronchial stents in children. Semin Pediatr Surg 2016;25:179-85.  Back to cited text no. 5
    
6.
Anton-Pacheco JL, Garcia-Hernandez G, Villafruela MA. The management of tracheobronchial obstruction in children. Minerva Pediatr 2009;61:39-52.  Back to cited text no. 6
    


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