Management of congenital bronchomalacia in an infant with high flow nasal cannula (HFNC)

Abstract

Background Congenital tracheobronchomalacia is the commonest lower airway abnormality in children with an estimated incidence of 1:1500 to 1:2500. Treatment modalities depend on severity ranging from conservative approach, CPAP support, stenting and surgical interventions. Methods The clinical progress of an infant with congenital right upper lobe segmental bronchomalacia presented as recurrent atelectasis being managed with high flow nasal cannula (HFNC) was described. Results A full term baby with progressive respiratory failure was intubated and managed as congenital pneumonia in the first week of life. Post-extubation, there was recurrent right upper lobe atelectasis and the baby remained dependent on nasal continuous positive pressure ventilation (nCPAP) at 4-5 cmH2O. Flexible bronchoscopy performed at 3 weeks old demonstrated congenital anatomical abnormalities of the right upper lobe bronchial tree including displacement of right upper lobe bronchus opening at the level of carina, bronchomalacia of the posterior segment and bifurcation with combined opening of the apical and anterior segments. Though respiratory status could be stabilised with nCPAP, there were problems of tolerance, interruption during feeding and limitations of home CPAP interfaces and device for small infants. Humidified HFNC at a flow rate of 2 litres/kg per min was later applied with good tolerance. Baby was successfully discharged at 2 months old and remained stable and thriving well with the home device used intermittently when awake and throughout the night during follow up at 4 months old. HFNC is getting more commonly used in children for acute respiratory support. It creates a positive pharyngeal pressure of about 4 cmH2O at a flow of 2 litres/kg/min in infants and is shown to decrease the work of breathing in various respiratory conditions. The pressure generated by HFNC is variable and may not be transmitted to lower airway as effective as CPAP for treatment of airway malacia, however, it could still be considered in less severe cases. Patients with congenital bronchomalacia usually improve with age, we expect our patient to be weaned off from respiratory support gradually. Conclusions HFNC may be considered as alternative option to CPAP treatment for moderate cases of congenital bronchomalacia for better tolerance and to facilitate early discharge.