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Editor—We read with interest the paper by Doull et alregarding tracheobronchomalacia in preterm infants with chronic lung disease.1 We have also recently investigated several infants with severe chronic lung disease who have become ventilator dependent. As part of our investigation, we assessed the large airways for evidence of tracheobronchomalacia using a flexible bronchoscope (Olympus BFN20 2.2 mm). We detected clinically significant airway collapse in a proportion of these infants and, like Doull et al, have found that a high opening pressure of up to 20 cm of water was required to improve this. We accept that the report by Doullet al suggests that a tracheobronchogram may detect tracheobronchomalacia, but we do not agree that this is superior to flexible bronchoscopy, and that the latter should be precluded, as implied by Doull and colleagues, for technical reasons. Flexible fibre optic bronchoscopy can be performed in infants using an adapted endotracheal tube connector which permits good airway control with the ability to ventilate the patient when necessary. The extent and severity of tracheobronchomalacia can be assessed directly and the airway pressure required to ablate airway collapse can be determined during the examination. More information regarding the distal airways and the presence of any focal structural lesions can be obtained by bronchoscopy than from tracheobronchography. We suggest that flexible fibre optic bronchoscopy should be the investigation of choice for suspected tracheobronchomalacia.
Dr Doull et al respond: We welcome Shaw and Smyth’s observations on the use of flexible bronchoscopy to diagnose trancheobronchomalacia, but feel that they have misconstrued our conclusions. In our discussion we make the point that trancheobronchography is more sensitive than rigid endoscopy for diagnosing trachobronchomalacia. We have also used flexible bronchoscopy in the diagnosis and assessment of tracheomalacia, and found it very useful. We agree with Smyth and Shaw that flexible bronchoscopy may offer superior information on distal focal structural lesions. However, in the chronically ventilated infant, with an endotracheal tube in situ, proximal focal structural lesions are almost certainly better visualised using rigid endoscopy. Combined upper and lower airways assessment is therefore essential, although clearly the optimal regimen has yet to be determined.