Opening Tiny Airways
Diego Preciado, M.D., Ph.D., a pediatric otolaryngologist at Children's National Medical Center in Washington, D.C., talks about a new procedure that widens narrow airways in babies and young children.
What this procedure is called and when it is necessary?
Dr. Diego Preciado: This is a laryngotracheoplasty, so it’s a laryngo-tracheal reconstructive procedure and it’s used when the airway -- the laryngeal airway or the upper trachea – is narrowed, either because somebody is born with a narrowed airway or usually from scarring, which often occurs secondary to endotracheal intubation.
Do you see it more frequently in premature babies, or is it anytime that the baby has to be intubated?
Dr. Preciado: Usually we see it slightly more frequently in children than in adults, and often even more in premature babies. The reason for that is because their airways are just naturally smaller and if they’re intubated, the tube creates perhaps more pressure on the walls of the upper airway, just below the vocal chords, and can induce scarring. It doesn’t happen very frequently, but approximately one in 300, one in 500 intubations in preemies or young children can lead to a narrowing.
When you say narrowing, does that mean they’re not getting enough air?
Dr. Preciado: Correct. That’s when the surgery would be indicated, if the airway is not adequate for them to be able to breathe and function and grow and live. Most of the time when children present, they present with respiratory and expiratory symptoms and also high-pitched noise because of the narrowed airway. Often these kids will hide how narrow their airway is. You can’t tell how they’re getting by, breathing through this really narrowed airway, but frequently, when they have increased respiratory demand -- such as when they’re upset -- breathing faster, breathing harder, or exerting themselves in any way, that’s when it becomes more apparent. Also, if they have a cold or phlegm or secretions, it blocks their airway further, and that’s when it becomes more apparent. In the worst cases, there can be episodes where they turn blue, or an increased respiratory demand to the point they need urgent medical intervention immediately.
How do you fix the narrow airways?
Dr. Preciado: Historically, and before the 80’s and early 90’s in children, this was treated by placing a tracheotomy tube -- a surgical airway tube that goes into the neck -- into the trachea, below the area of narrowing such that you bypass the area of narrowing and the kids would breathe through a tracheotomy tube for a long period of time. Then this surgery was introduced in the early 80’s by Dr. Roland Cotton and that became a way of fixing the narrowed airway. Now it always became a matter of debate as to when the best time is to fix the narrowing -- Is it early on in the child’s life, when they’re preemies or do you wait for the child to grow for the surgery to be successful? That, in many ways, hasn’t necessarily been defined completely, but it appears that even very young children, even babies, can have successful repair of a narrowed airway. If you look at the medical literature in the larger series of patients that underwent this surgery, age, in and of itself, was not a risk factor for failure of the procedure, and that’s why I feel, in my experience, that even young children do well, with the surgery.
What are the risks of this procedure?
Dr. Preciado: The primary risk of this procedure is that it doesn’t work to spread the airway open, and a child needs a tracheotomy afterwards. You make the pathology worse in trying to fix it early on, such that when you fix it later on, it’s harder to fix. Also, like any surgery in the airway, there are risks of infection, bleeding, airway obstruction, et cetera. If my babies had this problem, I would go for the surgery. I would try to avoid the trach because of all the issues that having a tracheotomy at such a young age entails.
What are the risks of a tracheotomy in babies?
Dr. Preciado: Having a tracheotomy at such a young age is not benign. You are really dependent on the trach tube to live, and the internal diameter of the trach tube is approximately three to 3.5 millimeters. Any mucus or phlegm that blocks the tube blocks your airway, so it requires very meticulous care, nursing care, suctioning and monitoring. You can imagine having a young baby with all the cares that are required and on top of that, you add a trach tube. It’s often too complex for families to take care of on their own. In fact, they always need 24 hour nursing or very frequently, they need to be in some sort of sub-acute care setting -- long-term care rehabilitation type hospital or nursing hospital, so it’s a big deal for the kids’ development. Approximately one percent of the time, if you look at the literature, kids can die because of a trach tube being blocked, so it’s not a benign treatment. That’s what convinces me to go for avoiding the trach and go for the reconstruction early on, even at a young age.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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