Elsevier

The Annals of Thoracic Surgery

Volume 88, Issue 6, December 2009, Pages 1970-1974
The Annals of Thoracic Surgery

Original article
Pediatric cardiac
Influence of Tracheobronchomalacia on Outcome of Surgery in Children With Congenital Heart Disease and Its Management

https://doi.org/10.1016/j.athoracsur.2009.08.039Get rights and content

Background

Patients with complex congenital heart disease associated with tracheobronchomalacia (TBM) remain difficult to manage after cardiac surgery. We studied the influence of TBM on the outcomes of pediatric patients after cardiac surgery for congenital heart disease to determine how to manage these patients better.

Methods

Twenty-two consecutive pediatric patients who had TBM diagnosed by bronchoscopy or dynamic contrast bronchography before or after cardiac surgery for congenital heart disease during a 5.5-year period were compared with an age- and procedure-matched control group operated on during the same period. Patients diagnosed postoperatively were investigated after a second failed extubation. Patients were managed by oxygen administration, endotracheal suctioning, and positive end-expiratory or continuous positive airway pressure through a nasotracheal tube or tracheostomy.

Results

There were 4 deaths within 1 year of surgery, all in the study group, with 2 early (neither of which appeared related to TBM) and 2 late. The estimated survival at 5 years was 82% (95% confidence interval, 59% to 93%) for the study group compared with 100% for control patients (p = 0.012). All deaths occurred in patients undergoing palliative procedures (p = 0.0004), and both children who underwent redo operations died (p = 0.02). Postoperatively, 50% of children with TBM required prolonged ventilation and tracheostomy. Compared with control patients the average postoperative ventilation time, pediatric intensive care unit stay, and hospital stay were 6.5, 11.5, and 20 days versus 1, 2, and 6.5 days, respectively (p < 0.001).

Conclusions

Although associated with longer postoperative ventilation time, pediatric intensive care unit stay, hospital stay, and mortality, outcomes after cardiac procedures in children with TBM are acceptable. Palliative and redo procedures in this group of patients are associated with significantly higher risk of death.

Section snippets

Material and Methods

Clinical records of two groups of pediatric patients who underwent cardiac surgery for congenital heart disease between June 1998 and December 2003 in our institution were reviewed. After consultation with the local ethics committee we were advised that as the study was an anonymous, retrospective service evaluation, formal ethical committee approval was not required. Of a cohort of 1,578 patients undergoing surgery for congenital heart disease in our unit during this time (1,094 open and 484

Results

In 12 patients the diagnosis of TBM was made preoperatively owing to respiratory distress requiring ventilation (n = 6), gastroesophageal reflux (n = 2), stridor (n = 3), or dyspnea (n = 1). The diagnosis was made postoperatively in 10 patients after failed extubation (n = 8), or because of gastroesophageal reflux (n = 1) or stridor (n = 1).

Bronchoscopy was performed in 19 patients (86%), and dynamic contrast tracheobronchography in 9 patients (41%). The diagnosis of TBM was confirmed solely by

Comment

Tracheobronchomalacia, although rare, is a common and important cause of persistent ventilatory requirement in infancy with a reported incidence of up to 50% [5, 6, 7, 8]. Children may present with clinical signs of airway obstruction, such as stridor, wheeze, cyanotic spells, and reflex apnea, or recurrent respiratory tract infections [3]. However, it may remain silent until the postoperative period when it becomes manifest by difficulty in ventilation or unexpected requirement for prolonged

References (11)

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    Severe TBM occurs frequently with absent pulmonary valve syndrome and vascular ring pathology, but also with many other variants of CHD. Among patients undergoing surgery for CHD, TBM is associated with increased duration of mechanical ventilation, intensive care unit stay, and mortality.8,9 The guiding principle of intervention in TBM is to improve airway function and clinical status of the patient.

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