Abstract
A working definition for tracheobronchomalacia in children is provided in the task force document published by the ERS in 2019. This may require review in due course as further research into the dynamic aspects of malacia and clinical correlation emerges. http://bit.ly/2rNuq08
From the authors:
We thank S. Crowley and K-H. Carlsen for their interest in the European Respiratory Society task force document on tracheomalacia and bronchomalacia (TBM) in children [1].
We agree that the definition of TBM is far from straightforward. The task force had to settle on a definition of malacia based on a systematic review of the literature combined with expert opinions from various parts of the world. The aim of the task force was to create a standard against which further work can be built. This is a working definition to advance the field as opposed to a single, poorly accepted, strict definition.
Many definitions of TBM in both children and adults exist, including those based only on a shape abnormality without any regard to a reduction in cross-sectional area [2]. Some include excessive dynamic airway collapse (EDAC) in the definition but others exclude EDAC to prevent overdiagnosis [3, 4]. As such, quiet breathing rather than forced coughing or Valsalva efforts in children is suggested to establish the baseline dynamic structure. The manoeuvre described by S. Crowley and K-H. Carlsen is likely to reveal EDAC rather than true cartilaginous tracheomalacia, although it is known that there is an overlap. Even in adult medicine where there is substantially more data, such controversy exists [5].
The authors correctly state that the controlled dynamic expiratory manoeuvres can only be done in older cooperative children. We were also mindful of the need in this paediatric statement to ensure that we did not generate false-positive findings in infants where the issues of malacia are particularly prevalent [6].
If dynamic expiratory studies are done in older children, investigators will need to consider if this is showing structural abnormities to the rings or EDAC. The subsequent correlation of these findings to the clinical symptoms is, of course, another story.
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Supplementary Material
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Footnotes
Conflict of interest: C. Wallis has nothing to disclose.
Conflict of interest: K. Priftis has nothing to disclose.
Conflict of interest: A. Chang received grants from National Health and Medical Research Council, Australia, has participated on a data monitoring committee for GSK, and has authored work for Up to Date and BMJ Evidence Centre, outside the submitted work.
Conflict of interest: F. Midulla has nothing to disclose.
Conflict of interest: J. Bhatt reports personal fees for lectures from Vertex, outside the submitted work.
- Received November 25, 2019.
- Accepted November 26, 2019.
- Copyright ©ERS 2019