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n, MD
ru, MDur Özçelik, MDHacettepe University Faculty of Medicine, Ankara, Turkey
Correspondence to: Ebru Yalçn, MD, Chest Diseases Unit, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100-Ankara, Turkey; e-mail: ebruy{at}hacettepe.edu.tr
To the Editor:
We read with interest the article by Boogaard et al (November 2005)1 in CHEST on tracheomalacia (TM) and bronchomalacia (BM) in children. They reported the incidence of those conditions and patient characteristics, and they calculated the predictive value of a clinical diagnosis of airway malacia by pediatric pulmonologists. However, certain points need clarification.
The authors detected airway malacia in 160 children at a median age of 4 years. The age of the oldest malacic patient was 17 years, which seems very old. We recently reported2 34 patients with TM and/or BM, whose median age was 9 months (range, 1.5 months to 5 years). We did not identify any malacic patient older than 5 years of age, although we performed flexible bronchoscopy in patients up to 18 years of age. We wonder what kind of diseases or conditions contributed to the persistence of malacia in patients from > 5 years of age to adolescence in the series by Boogaard et al.1 The authors calculated the incidence of primary airway malacia based on the annual birth rate; however, this means of calculation taking into consideration only the annual birth rate does not seem reasonable.
In our series,2 we also evaluated the clinical and radiologic characteristics of our malacic patients, and we demonstrated that BM was associated with parenchymal findings more often than TM. In the presence of BM (with TM or alone), wheezing, recurrent or persistent pneumonia, and unilateral persistent atelectasis were common findings. Were there also any clinical and/or radiologic findings in the study of Boogaard et al?1
Boogaard et al1 reported that the diagnosis was confirmed by bronchoscopy in 74% of patients who were suspected of having airway malacia by pediatric pulmonologists. The authors had better detailed information and comments on which to base clinical signs and symptoms that would be predictive for the presence of malacic disorders.
The authors found that most of the patients with isolated airway malacia had no evidence of gastroesophageal reflux (GER) based only on the lipid-laden macrophage index,1 which was not consistent with that in other reports.23 They also explained this difference in their study with the exclusion of patients who had associated syndromes or medical conditions (who are at greater risk for aspiration). If GER was investigated not only by the lipid-laden macrophage index but also by other techniques (eg, barium esophagography, 24-h esophageal monitoring, or gastric scintigraphy), they could have found more patients with GER. We detected GER, which was most commonly seen in those patients with tracheobronchomalacia, in 29% of the patients in our study.2
This may support the occurrence of the highest intrapleural negative pressure in these children than in those with TM or BM alone. Since GER can aggravate malacia symptoms, its treatment is important.23 It should also be emphasized that, since therapy with ß-adrenergic bronchodilator agents aggravates airway obstruction by reducing airway muscle tone, their use should be avoided in malacic disorders.4
Footnotes
The authors have no conflicts of interest to disclose.
References
n, E, Doru, D, Özçelik, U, et al Tracheomalacia and bronchomalacia in 34 children: clinical and radiological profiles and associations with other diseases. Clin Pediatr 2005;44,777-781
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