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Stridor in the Infant Patient

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Fig. 6. Appearance of normal distal trachea ( A ) and severe tracheomalacia ( B ).

also be acquired owing to longstanding intubation trauma or subsequent tracheot omy, which can weaken tracheal cartilage. Collapse of the tracheal cartilage can lead to barking cough, frequent respiratory infections, and cyanotic episodes. Defin itive diagnosis is necessary with rigid endoscopy or tracheoscopy to visualize dynamic collapse of the airway in an anteroposterior fashion. Treatment is typically conserva tive management and continuous positive pressure ventilation in the setting of trache ostomy tube placement. 35 Most infants will improve within 6 to 12 months of age as the cartilage develops, but the condition can be long-lasting and worsen with age depending on the underlying cause. 1 In severe cases of vascular compression result ing in tracheomalacia, anterior aortopexy or posterior tracheopexy is necessary to resolve airway obstruction. Placement of a tracheostomy tube or distal airway stent can be used in refractory disease but should be avoided because of the high likelihood of permanent tracheal damage. They are to be used in urgent or emergent conditions in patients whose prognosis is unlikely to improve without open surgical intervention. 35 Complete Tracheal Rings Complete tracheal rings are a birth defect secondary to abnormal growth of the carti lage during gestation. In a normally developed trachea, the cartilage distal to the cricoid is in a C-shaped ring with trachealis muscle forming the posterior border. A tra chea with complete rings will have rigid O-shaped rings throughout the length of the trachea, resulting in a narrowed airway. The condition is typically associated with car diovascular anomalies, Down syndrome, or Pfeiffer syndrome. Children will present with noisy breathing, stridor, wheezing, apnea, and recurrent pneumonia. Diagnosis is with rigid endoscopy and imaging (CT scan or MRI scan). Mild presentation can be watched conservatively until definitive management may be necessary. Children with severe presentation will require definitive surgery, such as tracheal resection or slide tracheoplasty. Because of the high likelihood of concomitant cardiovascular anomalies, these procedures should be performed alongside cardiovascular surgery. Infectious Stridor Stridor of an infectious cause is not typically seen in the neonatal or infant age group and is more common in older children. However, when stridor presents acutely, the most common cause is laryngotracheobronchitis, or croup. 36 Croup causes subglottic edema, which results in an expiratory barking cough along with an inspiratory stridor.

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