Conservative management of pediatric tracheal rupture

Conservative management of posterior tracheal wall injury by endoscopic stent placement in children: Preliminary data of three cases

The management of tracheal wall lacerations is debated. Current treatments are mainly derived by the experience on adults and include conservative or surgical treatments depending on the clinical condition of the patient. We report our preliminary data with removable tracheal stents in 3 children with tracheal tears and respiratory failure. If performed in specialized centers with appropriate endoscopic and clinical follow-up, airway stents can be considered a valid and safe conservative treatment for tracheal tears and an alternative to intubation or tracheostomy. Further studies are needed to compare different therapeutic options and better define the management and duration of stent treatment.

Traumatic Pediatric Tracheal Rupture After Blunt Force Sporting Injury: Case Report and Review of the Literature

OBJECTIVE

This paper presents the case of a traumatic tracheal rupture in a pediatric patient. The body of literature of the clinical features, evaluation, and management of this uncommon presentation is discussed.

CASE

A 13-year-old boy sustained an intrathoracic tracheal rupture whilst playing Australian Rules football. He developed hallmark clinical features of air extravasation and was intubated prior to transfer to a tertiary pediatric center for further management. After a short trial of conservative management, his respiratory status deteriorated and he was taken to the operating theater for open surgical repair of the defect.

CONCLUSION

Traumatic rupture of the trachea is a rare injury in children. This case demonstrates the dynamic nature of this serious injury and the need for multidisciplinary care in achieving the optimal outcome.

Pediatric tracheal trauma

Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.

Pediatric tracheal injuries: Report on 5 cases with special view on the role of bronchoscopy and management

INTRODUCTION

The purpose of these case reports is to draw the attention to the difficulties of diagnosing trachea injuries in children, who are often part of a polytrauma scenario.

MATERIALS

A retrospective multicenter analysis of 5 cases were analysed. The age of the children was between 1 and 16 years old. Injury mechanism was blunt thoracic trauma, misintubation and shot injury.

RESULTS

Case No.1. a three-year-old child suffered a train accident. Resuscitation and decompression of the tension pneumothorax were performed. CT found a pneumomediastinum and bubbles along the trachea. Thoracolaparotomy was performed. Bronchoscopy could not rule out a tracheal injury. The child died of a cerebral edema. Case No. 2: a 13 month drowned and was resuscitated. A chest drain was inserted to treat the pneumothorax. CT revealed a pneumomediastinum, which was drained and a small tear of the trachea. Bronchoscopy was not preformed. Case No. 3: 9 year-old polytrauma patient was airlifted with bilateral mini thoracostomies and chest drains for pneumothorax. CT revealed bilateral pneumothorax and pneumomediastinum. The chest drains were repositioned oxygenation improved, but some ventilation difficulties remained. CT revealed pneumomediastinum and a tracheal injury. This was bridged by a tube, and the mediastinum drained. The ventilation difficulties were resolved. Case No. 4: an eight-year-old boy was shot on the neck. The region was explored surgically and the laceration of the trachea was sutured. Case No. 5: 12-year-old girl suffered blunt thoracic trauma. CT revealed bilateral pneumothorax and pneumomediastinum. Bilateral thoracic drainage was performed, some ventilation problems persisted. CT and fiberoscopy revealed a rupture of the trachea. Thoracotomy was performed and the laceration was closed.

CONCLUSION

Pneumomediastinum and persistent ventilation difficulties should raise suspicion of a tracheal injury in a typical clinical scenario. Bronchoscopy is recommended for early diagnosis, despite the possibility of misdiagnosis. In certain cases CT scan only and close observation may be considered.

Management of the Disrupted Airway in Children

OBJECTIVE

Our objective was to gather data that would enable us to suggest more specific guidelines for the management of children with airway disruption.

STUDY DESIGN

Retrospective case series with data from five tertiary medical centers.

METHODS

Children younger than 18 years of age with a disrupted airway were enrolled in this series. Data pertaining to age, sex, etiology and location of the disruption, type of injury, previous surgery, presence of air extravasation, management, and outcome were obtained and summarized.

RESULTS

Twenty children with a mean age of 4.4 years (range 1 day-14.75 years) were included in the study. All were evaluated by flexible endoscopy and/or microlaryngoscopy in the operating room. Twelve (60%) children had tracheal involvement; seven had bronchial involvement; and one had involvement of the cricoid cartilage. Nine children had air extravasation, and all these children required surgical repair. Of the 11 who did not have air extravasation, only one underwent surgical repair. Complete healing of the disrupted airway was seen in all cases.

CONCLUSION

This series suggests that if there is no continuous air extravasation demonstrated on imaging studies or clinical examination, nonoperative management may allow for spontaneous healing without sequelae. However, surgical repair may be considered in those patients with continuous air extravasation unless a cuffed tube can be placed distal to the site of injury. For children in whom airway injury occurs in a previously operated area, the risk of extravasation is reduced. This risk is also diminished if positive pressure ventilation can be avoided or minimized.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:921-924, 2021.

Tetralogy of Fallot: Everything you wanted to know but were afraid to ask

Tetralogy of Fallot (TOF) has four anatomic features: right ventricular hypertrophy (RVH), ventriculoseptal defect (VSD), overriding aorta and right ventricular outflow tract obstruction (RVOT) with an occurrence of 3.9 /10,000 births. The pathophysiologic effects in TOF are largely determined by the degree of RVOT and not the VSD. Intra-operative anesthetic management is also dependent on the degree of RVOT obstruction and influenced by the extent of surgical RVOT repair.

Assessment of airway abnormalities in patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals

BACKGROUND

Children with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals (TOF/MAPCAs) are at risk for post-operative respiratory complications after undergoing unifocalisation surgery. Thus, we assessed and further defined the incidence of airway abnormalities in our series of over 500 children with TOF/MAPCAs as determined by direct laryngoscopy, chest computed tomography (CT), and/or bronchoscopy.

METHODS

The medical records of all patients with TOF/MAPCAs who underwent unifocalisation or pulmonary artery reconstruction surgery from March, 2002 to June, 2018 were reviewed. Anaesthesia records, peri-operative bronchoscopy, and/or chest CT reports were reviewed to assess for diagnoses of abnormal or difficult airway. Associations between chromosomal anomalies and airway abnormalities - difficult anaesthetic airway, bronchoscopy, and/or CT findings - were defined.

RESULTS

Of the 564 patients with TOF/MAPCAs who underwent unifocalisation or pulmonary artery reconstruction surgery at our institution, 211 (37%) had a documented chromosome 22q11 microdeletion and 28 (5%) had a difficult airway/intubation reported at the time of surgery. Chest CT and/or peri-operative bronchoscopy were performed in 234 (41%) of these patients. Abnormalities related to malacia or compression were common. In total 35 patients had both CT and bronchoscopy within 3 months of each other, with concordant findings in 32 (91%) and partially concordant findings in the other 3.

CONCLUSION

This is the largest series of detailed airway findings (direct laryngoscopy, CT, and bronchoscopy) in TOF/MAPCAS patients. Although these findings are specific to an at-risk population for airway abnormalities, they support the utility of CT and /or bronchoscopy in detecting airway abnormalities in patients with TOF/MAPCAs.

Pediatric pulmonology year in review 2017: Part 1

Pediatric Pulmonology publishes original research, case reports and review articles on topics related to a wide range of children's respiratory disorders. In this article (Part 1 of a series), we summarize the past year's publications in our major topic areas, as well as selected literature in these areas from other journals. In Part 1, we review selected articles on diagnostic testing/endoscopy, respiratory complications of neuromuscular disorders, and rare lung diseases.