Tracheomalacia
Noisy Breathing
or Barky Cough
Is your child struggling with noisy breathing or a barky cough? Learn about tracheomalacia, its causes, and advanced treatment options.
What is Tracheomalacia?
Tracheomalacia is a condition where the walls of the windpipe (trachea) are soft or weak, making it floppy. This can cause the trachea to partially collapse, especially when your child exhales (breathes out), leading to noisy breathing or breathing difficulties.
What Causes Tracheomalacia?
There are two main types:
Congenital Tracheomalacia
- Present at birth
- Caused by abnormal development of the tracheal cartilage
- Often occurs with other airway or esophageal conditions (e.g., TE fistula, laryngomalacia)
Acquired Tracheomalacia
- Develops later, often after prolonged intubation (breathing tube)
- Can also be caused by external compression (e.g., vascular ring or mass)
Symptoms of Tracheomalacia
Children with tracheomalacia may show symptoms such as:
- Noisy breathing (especially during exhaling or crying)
- “Honking” cough or a barky, seal-like cough
- Frequent respiratory infections or wheezing
- Difficulty feeding or choking during meals
- Cyanosis (turning blue during crying or feeding)
- Breathing problems that worsen with colds or lying on the back
How is Tracheomalacia Diagnosed?
Diagnosis involves several steps:
Flexible Bronchoscopy
- A small camera is inserted into the airway while the child is awake or asleep
- This is the gold standard to directly observe tracheal collapse
Imaging Tests
- CT scan with airway protocol or MRI to assess for vascular compression
- Fluoroscopy to watch how the airway moves during breathing
Other Tests
- Sleep study (if nighttime breathing issues)
- Swallow study (if choking or aspiration is suspected)
How is Tracheomalacia Treated?
Most children with mild tracheomalacia outgrow it by age 2-3 as the airway stiffens. Treatment depends on the severity:
Mild Cases
- Reassurance and regular follow-up
- Positioning techniques (upright feeding, side sleeping if safe)
- Managing reflux (GERD), which can worsen symptoms
Moderate Cases
- Inhalers or steroids during infections
- Antibiotics for frequent infections
- Close monitoring by a pediatric ENT or pulmonologist
Severe Cases
- Positive airway pressure (CPAP) or BiPAP to keep the airway open
- Surgery (e.g., aortopexy or tracheopexy) if caused by vascular compression or life-threatening symptoms
- Tracheostomy in rare cases with significant airway collapse
When is Surgery Needed for Tracheomalacia?
Aortopexy, Tracheopexy, 3D Splint
Explore surgical treatments for severe tracheomalacia in children, including aortopexy, posterior tracheopexy, and 3D-printed airway splints.
While many children with tracheomalacia outgrow it with time, some have severe symptoms that interfere with breathing, feeding, or growth. Surgery is considered when:
- The airway collapses so much that it causes life-threatening breathing problems
- The child experiences frequent respiratory infections or pneumonia
- There is failure to thrive due to airway obstruction
- Symptoms don’t improve despite medical treatment
Aortopexy
Lifting the aorta to relieve pressure on the trachea
What it is:
In some children, the main artery from the heart (aorta) compresses the front of the windpipe. Aortopexy is a procedure where the aorta is stitched to the back of the breastbone, lifting it away from the trachea.
How it helps:
This relieves pressure on the front wall of the trachea, allowing it to stay open during breathing.
How it’s done:
- Performed via a small chest incision (open or minimally invasive)
- Often done with the help of a pediatric cardiac surgeon
- May be combined with bronchoscopy during surgery to check airway movement
Recovery:
- Most children stay in the hospital for a few days
- Breathing typically improves immediately or within a few weeks
Posterior Tracheopexy
Supporting the back wall of the trachea to prevent collapse
What it is:
In many cases, the back wall (posterior wall) of the trachea is floppy and collapses inward with every breath. Posterior tracheopexy is a procedure where the back of the trachea is stitched to the front of the spine, holding it open.
How it’s done:
- Typically performed through a small incision behind the breastbone
- May be combined with aortopexy if both front and back wall issues exist
- Often done alongside bronchoscopy to confirm success
Who needs it:
- Children with severe posterior wall collapse
- Often associated with esophageal atresia or TE fistula repair
Benefits:
- Dramatically improves airflow
- Reduces coughing, noisy breathing, and respiratory infections
3D-Printed Tracheal Splint
Custom airway support for the most severe cases
What it is:
For children with life-threatening airway collapse that doesn’t respond to other treatments, a 3D-printed bioresorbable tracheal splint can be used.
How it works:
- Created using a CT scan of the child’s airway
- Custom-designed to fit around the collapsing section of trachea
- Provides a scaffold that supports the airway from the outside
- Over time, the splint dissolves naturally as the child’s trachea strengthens
How it’s placed:
- Requires open surgery
- May be combined with other airway procedures
- Typically used in select, high-risk patients in specialized centers
Advantages:
- Lifesaving for children with severe, long-segment collapse
- Avoids the need for long-term tracheostomy in some cases
Dr. Sohit Kanotra and the multidisciplinary airway team at ENTPediatric.com specialize in complex airway surgery. We collaborate with pediatric surgeons, pulmonologists, and cardiac specialists to provide the most advanced and personalized surgical care for children with tracheomalacia, including access to cutting-edge techniques like 3D-printed splints.
Related Links
Stridor
Learn about causes, symptoms, and treatments for stridor in children.
Laryngomalacia
Learn about laryngomalacia (Floppy Voice Box).
Subglottic and Tracheal Stenosis
Discover expert care for subglottic and tracheal stenosis in children.