Rationale: Dynamic collapse of the tracheal lumen (
tracheomalacia) occurs frequently in premature neonates, particularly in those with common comorbidities such as
bronchopulmonary dysplasia. The tracheal collapse increases the effort necessary to breathe (work of breathing [WOB]). However, quantifying the increased WOB related to
tracheomalacia has previously not been possible. Therefore, it is also not currently possible to separate the impact of
tracheomalacia on patient symptoms from parenchymal abnormalities.Objectives: To measure the increase in WOB due to airway motion in individual subjects with and without
tracheomalacia and with different types of respiratory support.Methods: Fourteen neonatal intensive care unit subjects not using invasive
mechanical ventilation were recruited. In eight,
tracheomalacia was diagnosed via clinical bronchoscopy, and six did not have
tracheomalacia. Self-gated three-dimensional ultrashort-echo-time magnetic resonance imaging (MRI) was performed on each subject with clinically indicated respiratory support to obtain cine images of tracheal anatomy and motion during the respiratory cycle. The component of WOB due to resistance within the trachea was then calculated via computational fluid dynamics (CFD) simulations of airflow on the basis of the subject's anatomy, motion, and respiratory airflow rates. A second CFD simulation was performed for each subject with the airway held static at its largest (i.e., most open) position to determine the increase in WOB due to airway motion and collapse.Results: The tracheal-resistive component of WOB was increased because of airway motion by an average of 337% ± 295% in subjects with
tracheomalacia and 24% ± 14% in subjects without
tracheomalacia (P < 0.02). In the
tracheomalacia group, subjects who were treated with
continuous positive airway pressure (CPAP) using a RAM
cannula expended less energy for breathing compared with the subjects who were breathing room air or on a high-flow
nasal cannula.Conclusions: Neonatal subjects with
tracheomalacia have increased energy expenditure compared with neonates with normal airways, and CPAP may be able to attenuate the increase in respiratory work. Subjects with
tracheomalacia expend more energy on the tracheal-resistive component of WOB alone than nontracheomalacia patients expend on the resistive WOB for the entire respiratory system, according to previously reported values. CFD may be able to provide an objective measure of treatment response for children with
tracheomalacia.