Should Neonatologists Rule Out Tracheobronchomalacia in Every Premature Baby With Bronchopulmonary Dysplasia?      Fadous Khalife et al, J Med Cases. 2019;10(3):72-7   

Commentary from Catherine: This current look at one of the possible adverse effects of prolonged intubation should inform our practice when supporting infants with CLD. Poor coordination and adverse events with PO that may lead to symptomatic or silent airway invasion may have their etiology in TBM. Keep this in your differential as you work with NICU infants who have CLD. Also our kids in PICU who present with persistent airway invasion in the setting of chronic respiratory co-morbidities. A direct laryngoscopy/bronchoscopy by ENT may be something to suggest as you work with your medical team. 

Excerpts:

Bronchopulmonary dysplasia (BPD) is a chronic inflammatory lung disease that affects mainly premature infants; it results from the damage to the immature lungs from mechanical ventilation and prolonged use of oxygen. They suffer from obstructive lung disease.

TBM in children is defined as weakening of the airway wall due to softening of the cartilaginous rings, decreased tone of the airway smooth muscle and collapse. This results in increased airway compliance and reduction of the size of the airway lumen during expiration. The clinical manifestations of malacia vary widely: barking cough, impaired mucous clearance, retractions, dyspnea and prolonged expiratory phase. Children can also have atelectasis and recurrent pneumonia leading sometimes to intubation and difficulty weaning from ventilator support. It may be associated with feeding difficulties.

The acquired type is most commonly associated with prolonged mechanical endotracheal intubation (with more significant effect in premature infants), severe tracheobronchitis and external tracheal compression (double aortic arch, innominate artery compression, vascular rings, left atrial enlargement).