Tracheal Injury |
| Tracheal
injuries in children are rare but potentially life-threatening. These
injuries may arise due to traumatic events, iatrogenic causes such as
intubation, or spontaneous occurrences linked to underlying conditions.
The clinical presentation varies depending on the severity and
mechanism of injury, making timely diagnosis and appropriate management
crucial. Pediatric tracheal trauma can be broadly categorized into blunt trauma, penetrating injuries, and iatrogenic injuries. Blunt trauma is often associated with motor vehicle accidents, falls, or sports-related impacts. The compliance and elasticity of a child's trachea make complete transections less common than in adults, yet injuries may be underdiagnosed due to their subtle presentation. Penetrating injuries, though less frequent, pose an immediate risk of airway compromise and often require surgical intervention. Iatrogenic injuries, particularly those due to endotracheal intubation, are a major concern in neonatal and pediatric intensive care units. The incidence of tracheal rupture following intubation varies but remains a critical issue, especially in cases requiring prolonged mechanical ventilation or repeated intubation attempts. The clinical manifestations of tracheal injury often include respiratory distress, subcutaneous emphysema, stridor, pneumothorax, and pneumomediastinum. Some cases present with acute airway obstruction, necessitating emergency intervention. Imaging modalities such as plain radiographs, computed tomography, and bronchoscopy are vital in diagnosing tracheal injuries. Flexible or rigid bronchoscopy remains the gold standard for confirming injury and guiding management decisions. Management strategies for tracheal injuries in children depend on the extent and location of the injury. Conservative management is gaining traction, particularly for minor injuries or stable patients. Reports suggest that in selected cases, spontaneous healing can be achieved with close monitoring, airway support, and judicious use of endotracheal tubes to bridge the injury. Stent placement has also been explored as an alternative to surgery, demonstrating promising outcomes in limited case series. However, when significant airway disruption or progressive respiratory compromise occurs, surgical intervention is warranted. Primary repair, end-to-end anastomosis, or tracheostomy may be required based on the severity and location of the injury. The risk of complications such as tracheal stenosis, tracheoesophageal fistula, and mediastinitis underscores the need for long-term follow-up. Studies have indicated that while many pediatric patients recover well with appropriate intervention, delayed sequelae can impact respiratory function. Conservative approaches often necessitate prolonged intubation or non-invasive ventilation to facilitate healing, though concerns remain regarding potential airway remodeling and stenotic changes. Emerging research highlights the importance of prevention strategies, particularly in the context of iatrogenic injuries. Optimizing intubation techniques, using appropriately sized endotracheal tubes, and limiting repeated intubation attempts are key measures in reducing iatrogenic tracheal injuries. Advances in airway management, including video laryngoscopy and improved sedation protocols, aim to enhance safety and minimize complications. Despite its rarity, tracheal injury in children demands heightened clinical awareness, early diagnostic intervention, and a multidisciplinary approach to management. The evolving preference for conservative management in selected cases represents a paradigm shift in treatment, though surgical intervention remains essential for severe injuries. Long-term surveillance is necessary to monitor for complications and ensure optimal respiratory outcomes in affected children. References: 1- Serio P, Fainardi V, Coletta R, Grasso A, Baggi R, Rufini P, Avenali S, Ricci Z, Morabito A, Trabalzini F: Conservative management of posterior tracheal wall injury by endoscopic stent placement in children: Preliminary data of three cases. Int J Pediatr Otorhinolaryngol. 159:111214, 2022 2- Hazkani I, Evans SS, Aaron G, Landry A: Management of severe cartilaginous pediatric tracheal injury. Pediatr Int. 64(1):e15148, 2022 3- Carratola M, Hart CK: Pediatric tracheal trauma. Semin Pediatr Surg. 30(3):151057, 2021 4- Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX Jr, Litman RS, Kovatsis PG: Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med. 4(1):37-48, 2016 5- Wood JW, Thornton B, Brown CS, McLevy JD, Thompson JW: Traumatic tracheal injury in children: a case series supporting conservative management. Int J Pediatr Otorhinolaryngol. 79(5):716-20, 2015 6- Schedlbauer EM, Todt I, Ernst A, Seidl RO: Iatrogenic tracheal rupture in children: A retrospective study. Laryngoscope. 119(3):571-5, 2009 7- McCann U, Kane K, Nicolette L, Ratner M, Baesl T. Primary repair of a neonatal bronchial intubation injury. J Pediatr Surg. 41(3):570-2, 2006 |
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