How we treat tracheomalacia – Esophageal and Airway Treatment Center | Boston Children’s Hospital


Different types of tracheomalacia require different types of treatment. Because we’re seeing tracheomalacia so often, and particularly because we’re seeing the type where the membrane moves up from the back, we developed a new treatment for this in about 2013. In the posterior intrusion type of tracheomalacia, we want to take the back membrane, which is moving in when the child exhales, we want to support it against the spine. In order to do that, we need to move some critical structures out of the way: the thoracic duct, the vagus nerves, and the esophagus. Now, when you’ve done those things, you have free access to attach the back membrane of the trachea down to the spine. Now, when you exhale, the spine holds that trachea open instead of allowing it to collapse. Almost in every case, fixing the back of the trachea makes them significantly better. Posterior tracheopexy. That’s our first line of treatment for almost all causes of tracheomalacia, even the type where the blood vessels come in from the front and collapse the trachea during development. Only about 10% of the time if we fix the back of the trachea first, do we have to then go on to the front. The reason we fix the back first is it makes fixing the front much less invasive and much more reliable. When we go from the front, we move the thymus gland, and often we just totally remove it. That gives us the space we need between the blood vessels and the sternum to work. Then, we literally place a series of sutures in the front of the trachea, and with a telescope inside the airway, watching what happens, we can pull up on each blood vessel to open that trachea wide open. Now because we’ve already fixed the back, when we pull that trachea forward, the back wall’s not just going to move with us. It’s going to stay where it is, so we only have to move the trachea, sometimes just a few millimeters to take the pressure off the front of the trachea. We’ve just talked about the two most common problems with airway collapse: the posterior intrusion type, where we treat that from the back, and the anterior collapse type, that we treat from the front, after we’ve treated the back. Well, there’s a third type, which is really airway compression caused by abnormal blood vessels. And those blood vessels are much stronger than the trachea, and so those blood vessels push in or squish the trachea from various angles. And in those cases, first you need a specially trained pediatric cardiovascular surgeon. They need an extensive evaluation, and then we work together to design the operation based on the anatomy. And that’s where we come in. We have a very close alliance with our cardiovascular folks to work to fix not just the heart, not just the blood vessels, but also the airway at the same time. The treatment comes in two phases. The first phase is to move the blood vessels out of the way so they are no longer pushing on the airway. And the second phase is then to fix the airway, which may or may not involve techniques we’ve already talked about. Posterior fixation or posterior tracheopexy to open up the back of the trachea, or maybe some anterior stitches to open up the front of the trachea. Each child has to have an operation designed specifically for that individual child. Recovery is really dependent on the lung function before surgery, but it’s also how well the child responded to the surgery. If their lungs are in good shape, they may go home in five or ten days. But if it took major cardiovascular reconstruction, with major heart surgery, then really, their airways are not going to be the limiting factor. It’s going to be the heart surgery that limits how fast they go home. Over the last three years, we’ve treated over 150 patients with severe tracheomalacia. All of those kids, once their airways have been reconstructed, their symptoms are nearly gone. Those who are going to school are now back in school, and those who are with their families are living an active life. We think this is a very effective strategy for treating a disease which is very under recognized.

4 thoughts on “How we treat tracheomalacia – Esophageal and Airway Treatment Center | Boston Children’s Hospital

  1. Can this treatment be done for adults with severe acquired tracheomalacia? Is anyone in the field doing it?

  2. How could someone not like this video, these drs are amazing and they’re changing lives for the better

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