Two imaging techniques to find too flexible an airway: looking for malacia

Infants who fail to wean from mechanical ventilation, or who do so only with considerably increased work of breathing and oxygen requirement, pose a major clinical challenge. Such infants are often preterm, but may also have cardiovascular, respiratory, or surgical comorbidities (tracheo-oesophageal fistula, diaphragmatic hernia, etc). They are prone to periodic, grumbling respiratory exacerbations and sometimes recurrent, frighteningly acute, severe respiratory compromise. Apportioning the relative contribution of chronic lung disease (or other comorbidity) to possible tracheobronchomalacia in the pathophysiology of these events is difficult, but this consideration is important in helping to inform effective management strategies.

In this issue, Mok et al discuss the relative merits of two methods for assessing malacia of the airway in ventilator dependent infants. Most of the infants in their report were preterm, although others have reported large cohorts of children with other comorbidities who also have associated tracheobronchomalacia.¹

The paper provides three messages, and raises three questions.

1. Tracheobronchomalacia was universal in their population of ventilator dependent preterm infants.

   • – How common is tracheobronchomalacia in the general preterm population and who should be investigated?

2. Safety remains an important consideration when investigating young infants.

   • – What is the best and safest way to obtain information on the dynamic function of the airways?

3. Continuous positive airway pressure (CPAP) therapy for tracheobronchomalacia can be titrated using imaging techniques.

   • – What therapeutic options are …