Tracheal work of breathing in neonates with tracheoesophageal fistula before and after surgical repair via computational fluid dynamics assessment

Introduction

Tracheoesophageal fistula (TEF), often occurring with esophageal atresia (EA), presents significant respiratory challenges in neonates. Neither the effect of EA/TEF, nor the effect of post-surgical complications such as tracheomalacia, on respiratory effort has been previously quantified. This study calculates the tracheal resistive component of work of breathing (TR-WOB) to quantify breathing effort pre- and post-surgical repair of EA/TEF. The primary objective of this study was to calculate the TR-WOB before and after surgical repair and compare it to normal values.

Methods

Five neonates with EA/TEF underwent ultrashort echo time (UTE) MRI before and after surgical repair. Virtual airway models were segmented from the MRI, with airway motion calculated via registration of respiratory-gated MRI. Computational fluid dynamic (CFD) simulations based on these virtual airways modeled patient-specific airflow calculated TR-WOB. Tracheal cross-sectional area (CSA) was quantified to reveal the relationship between airway anatomy and TR-WOB.

Results

Mean TR-WOB decreased from 686 ± 1013 J/day pre-surgery to 116 ± 159 J/day post-surgery (p = 0.299, Cohen's d = 0.301). In some subjects, TR-WOB remained elevated post-surgically compared to healthy neonates reported in previous studies. Four of five subjects showed increased tracheal CSA post-surgery (23 % mean increase). A strong negative correlation was found between average CSA and TR-WOB post-surgery (ρ = −0.90, p = 0.037), suggesting anatomical improvements reduce breathing effort.

Conclusion

Surgical repair of EA/TEF reduces TR-WOB, but TR-WOB remains abnormally high in some patients. CFD-based assessments offer a quantitative tool for identifying neonates who may benefit from additional interventions to reduce TR-WOB during their EA-TEF repair.

Level of Evidence

4 Case Series.