Bronchoscopic and interventional management of tracheobronchomalacia in children with bronchopulmonary dysplasia: a review of evidence

Tracheobronchomalacia (TBM) remains a challenging condition in pediatric respiratory medicine. It arises from diverse etiologies involving intrinsic tracheal collapse and extrinsic airway compression. Although diagnostic criteria have progressed over time, flexible bronchoscopy remains the gold standard, as it enables direct assessment of dynamic airway changes, with a >50% reduction in airway lumen during forced expiration considered indicative of TBM. TBM represents one of the principal consequences of bronchopulmonary dysplasia (BPD) and plays a decisive role in the clinical course of affected children. The pathophysiological connection between BPD and TBM stems from multiple factors: prolonged mechanical ventilation, chronic inflammation, and altered development of airway cartilage in premature infants. Pharmacological treatment plays a key role in managing large airway disease (LAD) in infants with severe BPD by optimizing airway stability and reducing respiratory distress. Chest physiotherapy can enhance mucociliary clearance and support respiratory mechanics in patients with TBM, while in more severe cases surgical or bronchoscopic interventions, such as airway stenting, are often required. TBM in the context of BPD adds substantial clinical complexity, necessitating a comprehensive understanding of disease mechanisms and individualized therapeutic strategies. Evidence supporting available interventions is heterogeneous; non-invasive ventilation strategies hold the strongest support from randomized controlled trials, whereas bronchoscopic and surgical procedures rely largely on observational studies, case series, and expert opinion. This variability underscores the need for further research, particularly controlled trials comparing different management strategies where ethically and practically feasible.