International Journal of Pediatric Otorhinolaryngology 79 (2015) 716–720
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Traumatic tracheal injury in children: A case series supporting conservative management Joshua W. Wood *, Blakely Thornton, C. Scott Brown, Jennifer D. McLevy, Jerome W. Thompson University of Tennessee Health Science Center, Department of Otolaryngology-Head & Neck Surgery, Memphis, TN, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 November 2014 Received in revised form 20 February 2015 Accepted 20 February 2015 Available online 2 March 2015
Objectives: Injuries to the tracheobronchial region are rare, but have the potential for rapid progression and can become life-threatening. Etiologies of non-penetrating tracheobronchial injuries include blunt cervical trauma, endotracheal intubation, and other iatrogenic causes. Several options for treatment ranging from conservative to surgical exist, but no single treatment has been implemented with consensus. While early surgical repair was once considered the cornerstone of therapy, evidence supporting conservative treatment continues to gain strength. Methods: All pediatric patients who suffered from non-penetrating injuries to the tracheobronchial tree who were treated by the Otolaryngology Service at a tertiary children’s hospital from May 2012 through March 2014 were recorded. A total of 8 patients were identified. The cases were collected from the patients treated by the Otolaryngology Department based on retrospective review. The available electronic medical records were reviewed for each patient. Data including type of injury, endoscopic assessment of injury, treatment received, and follow-up were collected. Results: The ages ranged from 2 to 15 years old, with a mean of 9.25 years old. Six of the eight patients had injuries related to endotracheal intubation. Each patient was taken to the operating suite for diagnostic direct laryngoscopy and bronchoscopy, and treated with initial conservative management. All but one of the patients was treated with endotracheal intubation, and the average length of intubation was 11.71 days. All of the injuries healed spontaneously without requiring initial open surgery. Five patients (62.5%) developed some degree of tracheal stenosis. Three patients (37.5%) required further surgery; one received a tracheostomy and two patients required balloon dilation. Conclusions: This case series is the largest to date documenting the outcomes of conservative treatment of non-penetrating traumatic tracheal injuries in children. By using initial conservative therapy, we were able to avoid open surgical procedures in many of our patients. We believe that this case series provides further support for conservative management for children with tracheobronchial injuries. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Tracheal injuries Post-intubation Tracheal rupture Pediatric airway
1. Introduction Injury to the tracheobronchial region can cause problems ranging from difficulty breathing to respiratory collapse and even death by airway obstruction. Tracheal injury from blunt trauma and iatrogenic causes are rare, but due to their severity and sequelae they should have a more definitive treatment regimen [1]. Several options for treatment of non-penetrating injuries ranging from conservative to surgical exist, but no single treatment or criteria has
* Corresponding author at: 910 Madison Ave, Suite 430, Memphis, TN 38163, United States. Tel.: +1 901 448 5885; fax: +1 901 833 8763. E-mail address: [email protected] (J.W. Wood). http://dx.doi.org/10.1016/j.ijporl.2015.02.025 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
been implemented with consensus. Understanding the symptoms, diagnostic modalities, and treatment options is critical to improving outcomes of patients suffering from these injuries. Early detection of these injuries is critical to improving outcomes. The most common presenting signs and symptoms of tracheobronchial injuries are subcutaneous emphysema, respiratory distress, pneumothorax, and pneumomediastinum. A low index of suspicion is needed for intervention in patients with any concerning clinical signs, especially those who have recently undergone intubation for any reason [2]. When clinical suspicion is high, radiological studies such as plain films and computerized tomography can help confirm the diagnosis. Management of iatrogenic tracheal injuries is controversial. While early surgical repair was once considered the cornerstone of
J.W. Wood et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 716–720
therapy, evidence supporting conservative treatment continues to gain strength [3]. In this series we present a series of 8 pediatric cases of tracheal injury from our institution to strengthen the evidence for a conservative management of traumatic tracheal injuries in children. 2. Methods We present 8 cases of tracheal injuries from May 2012 through March 2014 at Le Bonheur Children’s Hospital in Memphis, Tennessee. The project was approved by the Institutional Review Board (IRB) at our institution, as well as through The University of Tennessee Health Science Center IRB. The cases were collected from the patients treated by the Otolaryngology Department based on retrospective chart review. Data including type of injury, endoscopic assessment of injury, treatment received, and followup were collected. The available electronic medical records were reviewed for each patient. 3. Results A total of 8 patients were treated for traumatic tracheal injuries at our institution from May 2012 to March 2014. The ages ranged from 2 to 15 years old, with a mean of 9.25 years old. There was a slight female preponderance of 62.5%. Four of the eight patients had been involved in motor vehicle or ATV accidents and had sustained traumatic injuries involving multiple organ systems. The average time from the initial traumatic injury or intubation to the presentation and diagnosis of tracheobronchial injury ranged from zero to 21 days, with an average of 8.32 days. The main symptoms that prompted evaluation by the Otolaryngology team were respiratory distress, stridor, or failure to tolerate extubation (see Table 1). All the patients were evaluated by direct laryngoscopy and bronchoscopy in the operating suite. Injuries ranged from mucosal tears, circumferential necrosis and mucosal sloughing, to tracheal rupture. Half of the injuries were seen in the immediate subglottic area, with the remainder of the injuries in the mid and distal trachea. Six of the eight patients had injuries related to endotracheal intubation, representing 75% of our patients. Of the two patients not related to intubation, one patient’s injury was iatrogenic during a balloon dilation procedure, and one from blunt cervical trauma (see Table 2). All of our patients were initially treated conservatively, which consisted of endotracheal intubation in seven of the eight patients, Table 1 Demographics of 8 patients with tracheobronchial injuries. Patient
Age
Sex
Reason for intubation
Time to Diagnosis (Days)
Urgent orthopedic surgery after MVA Low GCS at the scene of ATV accident Altered mental status in ED N/A N/A Emergent craniotomy after MVA Status asthmaticus in ED Respiratory distress in PICU
9
1
7
M
2
13
M
3
8
F
4 5 6
8 15 6
F F F
7
2
8
15
M F
717
Table 2 Location and type of injury seen in our 8 patients with tracheobronchial injuries. Patient
Injury
Location
Etiology
1
Circumferential sloughing
ETT
2 3 4 5 6 7
Sloughing/necrosis Posterior tracheal rupture Anterior mucosal tear Posterior mucosal tear Necrosis, stenosis Necrotic posterior wall, exposed cartilage, stenosis Circumferential sloughing, stenosis
Distal trachea, mid trachea Subglottic Mid-trachea Mid-trachea Mid-trachea Subglottic Subglottic
ETT ETT Blunt trauma Iatrogenic ETT ETT
Subglottic
ETT
8
ETT, endotracheal tube; SGS, subglottic stenosis.
in conjunction with muscle paralysis, anti-reflux therapy and systemic steroid administration. The average length of intubation was 11.71 days. The total number of surgeries ranged from 1 to 8, with the average being 4.1 per patient. All of the injuries healed spontaneously, and none of our patients required initial open surgical repair of their original injury. Five patients (62.5%) developed some degree of stenosis: two patients had Grade I stenosis, one patient had Grade II stenosis, and two patients had Grade III stenosis [4]. Three patients (37.5%) required further surgery; one received a tracheostomy and two patients required balloon dilation for subglottic stenosis (see Table 3). Endoscopic photographs of representative cases are shown in Fig. 1. These cases were chosen because they give a good representation of the types of injuries, and the outcomes that were achieved with conservative management. Patient 1 was a 7year-old male who was involved in a motor vehicle accident who suffered multiple traumatic injuries and intubated in the operating room the following morning for an orthopedic procedure. He failed multiple extubation attempts and developed subcutaneous crepitus and stridor. A direct laryngoscopy was performed and showed a circumferential tracheal mucosal tear in the mid-trachea and a second lesion in the distal trachea consisting of circumferential mucosal sloughing. He was intubated, with the tip of the tube was placed distal to both injury sites to bridge the site of injuries. He was kept intubated for a total of two weeks, and repeat endoscopies showed complete healing of the injuries with no stenosis. Patient 3 was an 8-year-old female who was involved in an allterrain vehicle accident. She suffered multiple traumatic injuries and was intubated in the emergency room due to decreased Table 3 Intervention and outcome of 8 patients with tracheobronchial injuries. Patient
Interventions
Length of intubation (days)
Total surgeries
Outcome
1
Intubation
20
2
2
Intubation
11
3
1 Intra-operative* 8
3 4 5 6
19 n/a 2 4
4 1 3 8
15
7
10
7
Mild Stenosis (I)
21
8
Intubation Observation Intubation Intubation, balloon dilation Intubation, balloon dilation Tracheostomy
Mild non-obstructing granulation tissue Mild non-obstructing eschar Mild Stenosis (I)* Asymptomatic Moderate Stenosis (III)** Moderate Stenosis (II)
16
2
Moderate stenoiss (III), Tracheostomy
3
1.25
ATV, all-terrain vehicle; ED, emergency department; GCS, Glasgow Coma Score; MVA, motor vehicle accident; PICU, Pediatric Intensive Care Unit. * Patient 5 suffered iatrogenic injury during balloon dilation for tracheal stenosis.
*
Grading of degree of stenosis is based on the Cotton-Meyer grading system. Patient #5 had moderate stenosis prior to iatrogenic injury, and her degree of stenosis unchanged after her injury. **
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Fig. 1. Endoscopic findings of representative cases. (A) and (B) Patient 1 with distal tracheal mucosal sloughing and complete resolution. (C) and (D) Patient 3 with a 3 cm posterior tracheal rupture with complete healing of the injury and mild stenosis (Grade I) from granulation tissue. (E) and (F) Patient 6 with necrosis and mucosal sloughing in the subglottic area that resulted in moderate (Grade I) stenosis.
consciousness. She was noted to have pneumomediastinum the next day on her routine chest X-ray. On endoscopy, she was noted to have a 3 cm elliptical laceration through the posterior wall of the trachea area exposing the esophageal musculature. The injury was bridged with an endotracheal tube and the patient was kept intubated and sedated. She had multiple repeat endoscopic evaluations documented granulation of the injury and complete healing with only mild stenosis. Patient 6 was a 6-year-old female involved in a MVA and sustained intracranial injuries. She was intubated in the operating room for an emergent craniotomy procedure. She developed stridor and respiratory distress following extubation on postoperative day #9. On endoscopy she was found to have circumferential necrosis and subglottic mucosa with sloughing and 75% airway obstruction. She was intubated, with the tip of the endotracheal tube distal to the injury. She underwent multiple balloon dilations and was able to be successfully extubated after 7 days.
Unfortunately, she developed Grade II stenosis that was not responding to balloon dilations and was referred for open airway procedures. 4. Discussion Although rare, tracheal injuries can carry heavy morbidity and mortality costs. The development of pneumomediastinum, pneumothorax, and mediastinitis lead to high rates of mortality [5]. Tracheal rupture may lead to creation of a false passage and subsequent inability to ventilate and quickly leads to death by respiratory collapse. Non-penetrating tracheal injuries often occur in the setting of blunt cervical trauma, but can also be caused by endotracheal intubation and other iatrogenic causes. The incidence of tracheal rupture during endotracheal intubation is between 0.04% and 0.12%, and even more rare in children [6]. Schedlbauer et al. reported that between 2000 and 2007 there were 18 cases of
J.W. Wood et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 716–720
tracheal injuries at their institution, and 4 of them were in children [7]. Further, all 4 of the pediatric cases were related to endotracheal intubation [7]. In our case series, the incidence of tracheobronchial injuries at our tertiary children’s hospital during the study period was 0.03%, and 75% of these were related to intubation. Iatrogenic injury may occur as a complication of endotracheal intubation endoscopic airway procedures. Injuries caused by endotracheal intubation often produce longitudinal tears in the posterior-lateral tracheal walls, and may even rupture the posterior wall [3]. Acute tracheal injury following intubation can occur due to direct trauma or from ischemic pressure necrosis. Many factors have been implicated in intubation-related tracheal injuries, including: traumatic intubation attempts, inappropriate use of stylets, inappropriate use of the laryngoscope, inappropriate tube size, over-inflation of the cuff, improper suctioning of the endotracheal tube, malposition of the tip of the tube, tube reposition without deflating the cuff, and abrupt head and neck movements [2,8–11]. These injuries range from mucosal tears, exposed cartilage, to complete tracheal rupture. Circumferential necrosis can occur as a result of an endotracheal tube that is too large or from over-inflation of the endotracheal tube cuff, and can lead to subglottic stenosis. In contrast, tracheal injuries from blunt cervical trauma often involve horizontal or irregularly shaped injuries along the tracheal wall [3]. This occurs as the trachea is compressed against the cervical spine [1]. The trachea itself is somewhat flexible, and protected by the sternum, clavicles and spine, thus blunt tracheal injuries are rare [1]. The pediatric airway has structural and physiological differences from the adult airway that predispose it to injury during intubation. The cricoid cartilage is the narrowest portion of the pediatric airway. This is the case until approximately eight years of age when the larynx takes on a more adult configuration in which the true vocal folds make up the narrowest portion of the airway [12]. Furthermore, the pediatric cricoid lumen is funnel-shaped with a narrower outlet than inlet. Thus, even an endotracheal tube that fits through the cricoid inlet may not fit through the subglottic outlet. In addition, the mucosa of the cricoid area lacks a substantial submucosal layer, leaving this area more prone to damage from compression and shearing forces [13]. Due to these anatomical differences, the pediatric airway is at increased risk for injuries during intubation. In addition to the structural differences in the pediatric airway, congenital anomalies such as laryngeal clefts and tracheal-esophageal fistulas have an increased risk of injury during intubation [10]. The higher cartilaginous elasticity and weaker inter-cartilaginous membranes have also been implicated in risk factors for pediatric tracheal injuries [10]. In patients who are suspected to have a tracheal injury, a high level of suspicion and early intervention are mandated. Subcutaneous emphysema and respiratory failure are the hallmark clinical findings [10]. Radiographic studies should include chest X-rays and lateral neck films to demonstrate the progression of subcutaneous emphysema, pneumothorax, and pneumomediastinum. Computed tomography is often helpful to further identify the injury, and barium swallow test may be used to rule out esophageal injuries [1]. The gold standard for diagnosis is visualization of the airway, either by flexible or rigid laryngoscopy and bronchoscopy [10]. While surgical management of tracheobronchial injuries was once considered the standard of care, recent publications, particularly in the adult literature, have showed increasing evidence that conservative management is often adequate [3,6,14]. The management of tracheal injuries vary, but the general consensus is that criteria for conservative management of tracheal injuries include: stable vital signs, easy ventilation, absence of respiratory distress, stable pneumomediastinum or subcutaneous
719
emphysema, and absence of sepsis [3,10,15]. Some authors report that lacerations >1 cm need operative intervention, while others say that the length of the injury has no bearing on the method of treatment [3,10]. There are significant risks in undergoing open airway procedures. Meyers reported a mortality rate of up to 70% in patients undergoing open surgical repair [16]. In patients who meet the above criteria for conservative management, the inherent risks of surgery are avoided, and long-term morbidity is minimized. In 2006, Conti et al. published a series of 30 adult patients with post-intubation tracheal bronchial rupture [3]. They showed that in patients who were breathing spontaneously at the time of diagnosis and were treated with non-invasive ventilation, full healing occurred in all patients. Of the 15 patients that required mechanical ventilation, either due to respiratory failure or other medical comorbidity, 13 were able to be treated conservatively by bridging the injury with an endotracheal tube distal to the site of injury [3]. Thus, only 2 patients, or 6.6%, required open surgical repair. They concluded that surgical repair should be used only if conservative measures and bridging techniques are not feasible due to either the patient’s overall condition or the site of the injury [3]. All of our patients in this series were treated initially with conservative management. This treatment was successful in avoiding open surgical repair in most cases. Only three of our eight patients required further surgical intervention, all of which were performed for tracheal stenosis. One patient developed Grade III subglottic stenosis and required tracheostomy tube placement. Two other patients required balloon dilation of tracheal stenosis due to Grade II and III stenosis. Thus, the majority of our patients avoided the risk and mortality seen in initial open repair of their injuries. One of our patients, Patient 5, had pre-existing Grade III tracheal stenosis. She suffered an iatrogenic tracheal tear during a balloon dilation procedure and was treated conservatively with endotracheal intubation only. She healed well from her injury and repeat endoscopies showed that her stenosis was stable when compared to her pre-injury endoscopic evaluation. She did go on have further balloon dilation procedures, but because these were related to the pre-existing stenosis and not a result of the iatrogenic injury, she is not included in the group reported as requiring further surgery. Intubation was required in all but one of our patients. The patient that did not require intubation had a small mucosal tear in the anterior tracheal wall from blunt cervical trauma. When intubation was required, the endotracheal tube was inserted under direct endoscopic visualization in the operating room and was placed distal to site the lesion. By bypassing the site of injury, we were able to provide ventilation and prevent further development of subcutaneous emphysema and pneumomediastinum, while allowing the lesion time to heal spontaneously. Beiderlinden successfully demonstrated immediate cessation of any air leaks from the trachea and resolution of subcutaneous emphysema and pneumothoraxes by implementing this method [17]. The injuries were reassessed regularly with direct laryngoscopy and bronchoscopy in order to ensure proper healing. Seven of the eight patients were successfully extubated, while the last required tracheostomy due to development of subglottic stenosis. In order to provide an adequate background for healing of these tracheal injuries, we used muscle paralytic agents, as well as antireflux and broad spectrum antimicrobial medications. Paralytics and sedation were utilized in our treatment regimen to ensure stability of the airway and allowed the tracheal injury to heal without further insults from movement of the endotracheal tube. The extent of the paralysis ranged from one to eight days depending on the severity of the injury. Our treatment was also
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coupled with anti-reflux and antimicrobial medications to further aid in providing an environment devoid of gastric secretions or infections. Although one patient developed pneumonia, this was treated with culture-directed antibiotics and resolved without complication. Ciprodex1 drops have been used for tracheal injuries and laryngeal granulomas at our institution for 3 years. This is an offlabel use of this medication, and there are currently no studies supporting or disputing the use of Ciprodex drops in this fashion. The potential risks with using this medication in this manner are the same as using it for approved uses, including secondary infections. They are administered by placing 3–5 drops into the lumen of a cuffless tracheostomy tube or cuffless endotracheal tube where they stimulate a cough reflex which distributes these drops diffusely throughout the entire upper airway. Using a cuffless tube allows the drops to pass around the tube to the site of the tracheal or laryngeal granulomas. Response to this treatment is usually present in 2 days to 2 weeks. We feel that this technique is able to aid in the healing of lesions, and allows for quicker extubation in many patients. To the best of our knowledge, this is the largest case series discussing conservative treatment in children with tracheobronchial injuries. In six of the eight patients, their injuries were related to endotracheal intubation. This further highlights the need for more research into intubation techniques and methods, and other ways that these iatrogenic injuries can be prevented. All eight of our patients were initially treated conservatively, and when intubation was required this consisted of bridging the defect with an endotracheal tube distal to the lesion. We acknowledge that there are circumstances where immediate open surgical repair is necessary, but those should be the exception rather than the rule. By using initial conservative therapy, we were able to avoid surgical procedures in most of our patients. We believe that this case series provides further support that conservative management for children with tracheobronchial injuries is safe, and can avoid open procedure in most patients.
References [1] D. Ye, Z. Shen, Y. Zhang, S. Qiu, C. Kang, Clinical features and management of closed injury of the cervical trachea due to blunt trauma, Scand. J. Trauma Resusc. Emerg. Med. 21 (2013) 60, http://dx.doi.org/10.1186/1757-7241-21-60. [2] D.S.F. Kacmarynski, J.D. Sidman, F.L. Rimell, V.A. Hustead, Spontaneous tracheal and subglottic tears in neonates, Laryngoscope 112 (2002) 1387–1393. , http:// dx.doi.org/10.1097/00005537-200208000-00012. [3] M. Conti, M. Pougeoise, A. Wurtz, H. Porte, F. Fourrier, P. Ramon, et al., Management of postintubation tracheobronchial ruptures, Chest 130 (2) (2006) 412–418. , http://dx.doi.org/10.1378/chest.130.2.412. [4] C.M. Myer, D.M. O’Connor, R.T. Cotton, Proposed grading system for subglottic stenosis based on endotracheal tube sizes, Ann. Otol. Rhinol. Laryngol. 103 (4 Pt 1) (1994) 319–323. [5] S.L. Goudy, F.B. Miller, J.M. Bumpous, Neck crepitance: evaluation and management of suspected upper aerodigestive tract injury, Laryngoscope 112 (2002) 791–795. [6] P. Borasio, F. Arndissone, G. Chimapo, Post-intubation tracheal rupture. A case report on ten cases, Eur. J. Cardiothorac. Surg. 12 (1997) 90–100. [7] E.M. Schedlbauer, I. Todt, A. Ernst, R.O. Seidl, Iatrogenic tracheal rupture in children: a retrospective study, Laryngoscope 199 (2009) 571–575. [8] L.C. Cunningham, K.R. Jatana, J.M. Grischkan, Conservative management of iatrogenic membranous tracheal wall injury, JAMA Otolaryngol. Head Neck Surg. 139 (4) (2013) 405–410. [9] J.L. Wei, J. Bond, Management and prevention of endotracheal intubation injury in neonates, Curr. Opin. Otolaryngol. Head Neck Surg. 19 (2011) 474–477. , http:// dx.doi.org/10.1097/MOO.0b013e32834c7b5c. [10] K.M. Doherty, A. Tabaee, M. Castillo, S.R. Cherukupally, Neonatal tracheal rupture complicating endotracheal intubation: a case report and indications for conservative management, Int. J. Pediatr. Otorhinolaryngol. 69 (2005) 111–116. [11] C.H. Marty-Ane, E. Picard, O. Jonquet, H. Mary, Membranous tracheal rupture after endotracheal intubation, Ann. Thorac. Surg. 60 (1995) 1367–1371. [12] J. Holzki, M. Laschat, C. Puder, Iatrogenic damage to the pediatric airway. Mechanisms and scar development, Pediatr. Anesthesiol. 19 (Suppl. 1) (2009) 131–146. [13] K. Sato, T. Nakashima, Histopathologic changes in laryngeal mucosa of extremely low-birth weight infants after endotracheal intubation, Ann. Otol. Rhinol. Laryngol. 115 (11) (2006) 816–823. [14] H.M. Ross, F.J. Grant, R.S. Wilson, M.E. Burt, Nonoperative management of tracheal laceration during endotracheal intubation, Ann. Thorac. Surg. 63 (1997) 240–242. [15] T. Schneider, Management of iatrogenic tracheobronchial injuries: a retrospective analysis of 29 cases, Ann. Thorac. Surg. 83 (2007) 1960–1964. [16] M. Meyer, Iatrogenic tracheobronchial lesions: a report on 13 cases, Thorac. Cardiovasc. Surg. 49 (2001) 115–119. [17] M. Beiderlinden, M. Adamzik, J. Peters, Conservative treatment of tracheal injuries, Anesth. Analg. 100 (2005) 210–214. , http://dx.doi.org/10.1213/01. ANE0000140780.1417505A.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Traumatic tracheal injury in children: A case series supporting conservative management Joshua W. Wood *, Blakely Thornton, C. Scott Brown, Jennifer D. McLevy, Jerome W. Thompson University of Tennessee Health Science Center, Department of Otolaryngology-Head & Neck Surgery, Memphis, TN, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 November 2014 Received in revised form 20 February 2015 Accepted 20 February 2015 Available online 2 March 2015
Objectives: Injuries to the tracheobronchial region are rare, but have the potential for rapid progression and can become life-threatening. Etiologies of non-penetrating tracheobronchial injuries include blunt cervical trauma, endotracheal intubation, and other iatrogenic causes. Several options for treatment ranging from conservative to surgical exist, but no single treatment has been implemented with consensus. While early surgical repair was once considered the cornerstone of therapy, evidence supporting conservative treatment continues to gain strength. Methods: All pediatric patients who suffered from non-penetrating injuries to the tracheobronchial tree who were treated by the Otolaryngology Service at a tertiary children’s hospital from May 2012 through March 2014 were recorded. A total of 8 patients were identified. The cases were collected from the patients treated by the Otolaryngology Department based on retrospective review. The available electronic medical records were reviewed for each patient. Data including type of injury, endoscopic assessment of injury, treatment received, and follow-up were collected. Results: The ages ranged from 2 to 15 years old, with a mean of 9.25 years old. Six of the eight patients had injuries related to endotracheal intubation. Each patient was taken to the operating suite for diagnostic direct laryngoscopy and bronchoscopy, and treated with initial conservative management. All but one of the patients was treated with endotracheal intubation, and the average length of intubation was 11.71 days. All of the injuries healed spontaneously without requiring initial open surgery. Five patients (62.5%) developed some degree of tracheal stenosis. Three patients (37.5%) required further surgery; one received a tracheostomy and two patients required balloon dilation. Conclusions: This case series is the largest to date documenting the outcomes of conservative treatment of non-penetrating traumatic tracheal injuries in children. By using initial conservative therapy, we were able to avoid open surgical procedures in many of our patients. We believe that this case series provides further support for conservative management for children with tracheobronchial injuries. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Tracheal injuries Post-intubation Tracheal rupture Pediatric airway
1. Introduction Injury to the tracheobronchial region can cause problems ranging from difficulty breathing to respiratory collapse and even death by airway obstruction. Tracheal injury from blunt trauma and iatrogenic causes are rare, but due to their severity and sequelae they should have a more definitive treatment regimen [1]. Several options for treatment of non-penetrating injuries ranging from conservative to surgical exist, but no single treatment or criteria has
* Corresponding author at: 910 Madison Ave, Suite 430, Memphis, TN 38163, United States. Tel.: +1 901 448 5885; fax: +1 901 833 8763. E-mail address: [email protected] (J.W. Wood). http://dx.doi.org/10.1016/j.ijporl.2015.02.025 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
been implemented with consensus. Understanding the symptoms, diagnostic modalities, and treatment options is critical to improving outcomes of patients suffering from these injuries. Early detection of these injuries is critical to improving outcomes. The most common presenting signs and symptoms of tracheobronchial injuries are subcutaneous emphysema, respiratory distress, pneumothorax, and pneumomediastinum. A low index of suspicion is needed for intervention in patients with any concerning clinical signs, especially those who have recently undergone intubation for any reason [2]. When clinical suspicion is high, radiological studies such as plain films and computerized tomography can help confirm the diagnosis. Management of iatrogenic tracheal injuries is controversial. While early surgical repair was once considered the cornerstone of
J.W. Wood et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 716–720
therapy, evidence supporting conservative treatment continues to gain strength [3]. In this series we present a series of 8 pediatric cases of tracheal injury from our institution to strengthen the evidence for a conservative management of traumatic tracheal injuries in children. 2. Methods We present 8 cases of tracheal injuries from May 2012 through March 2014 at Le Bonheur Children’s Hospital in Memphis, Tennessee. The project was approved by the Institutional Review Board (IRB) at our institution, as well as through The University of Tennessee Health Science Center IRB. The cases were collected from the patients treated by the Otolaryngology Department based on retrospective chart review. Data including type of injury, endoscopic assessment of injury, treatment received, and followup were collected. The available electronic medical records were reviewed for each patient. 3. Results A total of 8 patients were treated for traumatic tracheal injuries at our institution from May 2012 to March 2014. The ages ranged from 2 to 15 years old, with a mean of 9.25 years old. There was a slight female preponderance of 62.5%. Four of the eight patients had been involved in motor vehicle or ATV accidents and had sustained traumatic injuries involving multiple organ systems. The average time from the initial traumatic injury or intubation to the presentation and diagnosis of tracheobronchial injury ranged from zero to 21 days, with an average of 8.32 days. The main symptoms that prompted evaluation by the Otolaryngology team were respiratory distress, stridor, or failure to tolerate extubation (see Table 1). All the patients were evaluated by direct laryngoscopy and bronchoscopy in the operating suite. Injuries ranged from mucosal tears, circumferential necrosis and mucosal sloughing, to tracheal rupture. Half of the injuries were seen in the immediate subglottic area, with the remainder of the injuries in the mid and distal trachea. Six of the eight patients had injuries related to endotracheal intubation, representing 75% of our patients. Of the two patients not related to intubation, one patient’s injury was iatrogenic during a balloon dilation procedure, and one from blunt cervical trauma (see Table 2). All of our patients were initially treated conservatively, which consisted of endotracheal intubation in seven of the eight patients, Table 1 Demographics of 8 patients with tracheobronchial injuries. Patient
Age
Sex
Reason for intubation
Time to Diagnosis (Days)
Urgent orthopedic surgery after MVA Low GCS at the scene of ATV accident Altered mental status in ED N/A N/A Emergent craniotomy after MVA Status asthmaticus in ED Respiratory distress in PICU
9
1
7
M
2
13
M
3
8
F
4 5 6
8 15 6
F F F
7
2
8
15
M F
717
Table 2 Location and type of injury seen in our 8 patients with tracheobronchial injuries. Patient
Injury
Location
Etiology
1
Circumferential sloughing
ETT
2 3 4 5 6 7
Sloughing/necrosis Posterior tracheal rupture Anterior mucosal tear Posterior mucosal tear Necrosis, stenosis Necrotic posterior wall, exposed cartilage, stenosis Circumferential sloughing, stenosis
Distal trachea, mid trachea Subglottic Mid-trachea Mid-trachea Mid-trachea Subglottic Subglottic
ETT ETT Blunt trauma Iatrogenic ETT ETT
Subglottic
ETT
8
ETT, endotracheal tube; SGS, subglottic stenosis.
in conjunction with muscle paralysis, anti-reflux therapy and systemic steroid administration. The average length of intubation was 11.71 days. The total number of surgeries ranged from 1 to 8, with the average being 4.1 per patient. All of the injuries healed spontaneously, and none of our patients required initial open surgical repair of their original injury. Five patients (62.5%) developed some degree of stenosis: two patients had Grade I stenosis, one patient had Grade II stenosis, and two patients had Grade III stenosis [4]. Three patients (37.5%) required further surgery; one received a tracheostomy and two patients required balloon dilation for subglottic stenosis (see Table 3). Endoscopic photographs of representative cases are shown in Fig. 1. These cases were chosen because they give a good representation of the types of injuries, and the outcomes that were achieved with conservative management. Patient 1 was a 7year-old male who was involved in a motor vehicle accident who suffered multiple traumatic injuries and intubated in the operating room the following morning for an orthopedic procedure. He failed multiple extubation attempts and developed subcutaneous crepitus and stridor. A direct laryngoscopy was performed and showed a circumferential tracheal mucosal tear in the mid-trachea and a second lesion in the distal trachea consisting of circumferential mucosal sloughing. He was intubated, with the tip of the tube was placed distal to both injury sites to bridge the site of injuries. He was kept intubated for a total of two weeks, and repeat endoscopies showed complete healing of the injuries with no stenosis. Patient 3 was an 8-year-old female who was involved in an allterrain vehicle accident. She suffered multiple traumatic injuries and was intubated in the emergency room due to decreased Table 3 Intervention and outcome of 8 patients with tracheobronchial injuries. Patient
Interventions
Length of intubation (days)
Total surgeries
Outcome
1
Intubation
20
2
2
Intubation
11
3
1 Intra-operative* 8
3 4 5 6
19 n/a 2 4
4 1 3 8
15
7
10
7
Mild Stenosis (I)
21
8
Intubation Observation Intubation Intubation, balloon dilation Intubation, balloon dilation Tracheostomy
Mild non-obstructing granulation tissue Mild non-obstructing eschar Mild Stenosis (I)* Asymptomatic Moderate Stenosis (III)** Moderate Stenosis (II)
16
2
Moderate stenoiss (III), Tracheostomy
3
1.25
ATV, all-terrain vehicle; ED, emergency department; GCS, Glasgow Coma Score; MVA, motor vehicle accident; PICU, Pediatric Intensive Care Unit. * Patient 5 suffered iatrogenic injury during balloon dilation for tracheal stenosis.
*
Grading of degree of stenosis is based on the Cotton-Meyer grading system. Patient #5 had moderate stenosis prior to iatrogenic injury, and her degree of stenosis unchanged after her injury. **
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Fig. 1. Endoscopic findings of representative cases. (A) and (B) Patient 1 with distal tracheal mucosal sloughing and complete resolution. (C) and (D) Patient 3 with a 3 cm posterior tracheal rupture with complete healing of the injury and mild stenosis (Grade I) from granulation tissue. (E) and (F) Patient 6 with necrosis and mucosal sloughing in the subglottic area that resulted in moderate (Grade I) stenosis.
consciousness. She was noted to have pneumomediastinum the next day on her routine chest X-ray. On endoscopy, she was noted to have a 3 cm elliptical laceration through the posterior wall of the trachea area exposing the esophageal musculature. The injury was bridged with an endotracheal tube and the patient was kept intubated and sedated. She had multiple repeat endoscopic evaluations documented granulation of the injury and complete healing with only mild stenosis. Patient 6 was a 6-year-old female involved in a MVA and sustained intracranial injuries. She was intubated in the operating room for an emergent craniotomy procedure. She developed stridor and respiratory distress following extubation on postoperative day #9. On endoscopy she was found to have circumferential necrosis and subglottic mucosa with sloughing and 75% airway obstruction. She was intubated, with the tip of the endotracheal tube distal to the injury. She underwent multiple balloon dilations and was able to be successfully extubated after 7 days.
Unfortunately, she developed Grade II stenosis that was not responding to balloon dilations and was referred for open airway procedures. 4. Discussion Although rare, tracheal injuries can carry heavy morbidity and mortality costs. The development of pneumomediastinum, pneumothorax, and mediastinitis lead to high rates of mortality [5]. Tracheal rupture may lead to creation of a false passage and subsequent inability to ventilate and quickly leads to death by respiratory collapse. Non-penetrating tracheal injuries often occur in the setting of blunt cervical trauma, but can also be caused by endotracheal intubation and other iatrogenic causes. The incidence of tracheal rupture during endotracheal intubation is between 0.04% and 0.12%, and even more rare in children [6]. Schedlbauer et al. reported that between 2000 and 2007 there were 18 cases of
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tracheal injuries at their institution, and 4 of them were in children [7]. Further, all 4 of the pediatric cases were related to endotracheal intubation [7]. In our case series, the incidence of tracheobronchial injuries at our tertiary children’s hospital during the study period was 0.03%, and 75% of these were related to intubation. Iatrogenic injury may occur as a complication of endotracheal intubation endoscopic airway procedures. Injuries caused by endotracheal intubation often produce longitudinal tears in the posterior-lateral tracheal walls, and may even rupture the posterior wall [3]. Acute tracheal injury following intubation can occur due to direct trauma or from ischemic pressure necrosis. Many factors have been implicated in intubation-related tracheal injuries, including: traumatic intubation attempts, inappropriate use of stylets, inappropriate use of the laryngoscope, inappropriate tube size, over-inflation of the cuff, improper suctioning of the endotracheal tube, malposition of the tip of the tube, tube reposition without deflating the cuff, and abrupt head and neck movements [2,8–11]. These injuries range from mucosal tears, exposed cartilage, to complete tracheal rupture. Circumferential necrosis can occur as a result of an endotracheal tube that is too large or from over-inflation of the endotracheal tube cuff, and can lead to subglottic stenosis. In contrast, tracheal injuries from blunt cervical trauma often involve horizontal or irregularly shaped injuries along the tracheal wall [3]. This occurs as the trachea is compressed against the cervical spine [1]. The trachea itself is somewhat flexible, and protected by the sternum, clavicles and spine, thus blunt tracheal injuries are rare [1]. The pediatric airway has structural and physiological differences from the adult airway that predispose it to injury during intubation. The cricoid cartilage is the narrowest portion of the pediatric airway. This is the case until approximately eight years of age when the larynx takes on a more adult configuration in which the true vocal folds make up the narrowest portion of the airway [12]. Furthermore, the pediatric cricoid lumen is funnel-shaped with a narrower outlet than inlet. Thus, even an endotracheal tube that fits through the cricoid inlet may not fit through the subglottic outlet. In addition, the mucosa of the cricoid area lacks a substantial submucosal layer, leaving this area more prone to damage from compression and shearing forces [13]. Due to these anatomical differences, the pediatric airway is at increased risk for injuries during intubation. In addition to the structural differences in the pediatric airway, congenital anomalies such as laryngeal clefts and tracheal-esophageal fistulas have an increased risk of injury during intubation [10]. The higher cartilaginous elasticity and weaker inter-cartilaginous membranes have also been implicated in risk factors for pediatric tracheal injuries [10]. In patients who are suspected to have a tracheal injury, a high level of suspicion and early intervention are mandated. Subcutaneous emphysema and respiratory failure are the hallmark clinical findings [10]. Radiographic studies should include chest X-rays and lateral neck films to demonstrate the progression of subcutaneous emphysema, pneumothorax, and pneumomediastinum. Computed tomography is often helpful to further identify the injury, and barium swallow test may be used to rule out esophageal injuries [1]. The gold standard for diagnosis is visualization of the airway, either by flexible or rigid laryngoscopy and bronchoscopy [10]. While surgical management of tracheobronchial injuries was once considered the standard of care, recent publications, particularly in the adult literature, have showed increasing evidence that conservative management is often adequate [3,6,14]. The management of tracheal injuries vary, but the general consensus is that criteria for conservative management of tracheal injuries include: stable vital signs, easy ventilation, absence of respiratory distress, stable pneumomediastinum or subcutaneous
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emphysema, and absence of sepsis [3,10,15]. Some authors report that lacerations >1 cm need operative intervention, while others say that the length of the injury has no bearing on the method of treatment [3,10]. There are significant risks in undergoing open airway procedures. Meyers reported a mortality rate of up to 70% in patients undergoing open surgical repair [16]. In patients who meet the above criteria for conservative management, the inherent risks of surgery are avoided, and long-term morbidity is minimized. In 2006, Conti et al. published a series of 30 adult patients with post-intubation tracheal bronchial rupture [3]. They showed that in patients who were breathing spontaneously at the time of diagnosis and were treated with non-invasive ventilation, full healing occurred in all patients. Of the 15 patients that required mechanical ventilation, either due to respiratory failure or other medical comorbidity, 13 were able to be treated conservatively by bridging the injury with an endotracheal tube distal to the site of injury [3]. Thus, only 2 patients, or 6.6%, required open surgical repair. They concluded that surgical repair should be used only if conservative measures and bridging techniques are not feasible due to either the patient’s overall condition or the site of the injury [3]. All of our patients in this series were treated initially with conservative management. This treatment was successful in avoiding open surgical repair in most cases. Only three of our eight patients required further surgical intervention, all of which were performed for tracheal stenosis. One patient developed Grade III subglottic stenosis and required tracheostomy tube placement. Two other patients required balloon dilation of tracheal stenosis due to Grade II and III stenosis. Thus, the majority of our patients avoided the risk and mortality seen in initial open repair of their injuries. One of our patients, Patient 5, had pre-existing Grade III tracheal stenosis. She suffered an iatrogenic tracheal tear during a balloon dilation procedure and was treated conservatively with endotracheal intubation only. She healed well from her injury and repeat endoscopies showed that her stenosis was stable when compared to her pre-injury endoscopic evaluation. She did go on have further balloon dilation procedures, but because these were related to the pre-existing stenosis and not a result of the iatrogenic injury, she is not included in the group reported as requiring further surgery. Intubation was required in all but one of our patients. The patient that did not require intubation had a small mucosal tear in the anterior tracheal wall from blunt cervical trauma. When intubation was required, the endotracheal tube was inserted under direct endoscopic visualization in the operating room and was placed distal to site the lesion. By bypassing the site of injury, we were able to provide ventilation and prevent further development of subcutaneous emphysema and pneumomediastinum, while allowing the lesion time to heal spontaneously. Beiderlinden successfully demonstrated immediate cessation of any air leaks from the trachea and resolution of subcutaneous emphysema and pneumothoraxes by implementing this method [17]. The injuries were reassessed regularly with direct laryngoscopy and bronchoscopy in order to ensure proper healing. Seven of the eight patients were successfully extubated, while the last required tracheostomy due to development of subglottic stenosis. In order to provide an adequate background for healing of these tracheal injuries, we used muscle paralytic agents, as well as antireflux and broad spectrum antimicrobial medications. Paralytics and sedation were utilized in our treatment regimen to ensure stability of the airway and allowed the tracheal injury to heal without further insults from movement of the endotracheal tube. The extent of the paralysis ranged from one to eight days depending on the severity of the injury. Our treatment was also
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coupled with anti-reflux and antimicrobial medications to further aid in providing an environment devoid of gastric secretions or infections. Although one patient developed pneumonia, this was treated with culture-directed antibiotics and resolved without complication. Ciprodex1 drops have been used for tracheal injuries and laryngeal granulomas at our institution for 3 years. This is an offlabel use of this medication, and there are currently no studies supporting or disputing the use of Ciprodex drops in this fashion. The potential risks with using this medication in this manner are the same as using it for approved uses, including secondary infections. They are administered by placing 3–5 drops into the lumen of a cuffless tracheostomy tube or cuffless endotracheal tube where they stimulate a cough reflex which distributes these drops diffusely throughout the entire upper airway. Using a cuffless tube allows the drops to pass around the tube to the site of the tracheal or laryngeal granulomas. Response to this treatment is usually present in 2 days to 2 weeks. We feel that this technique is able to aid in the healing of lesions, and allows for quicker extubation in many patients. To the best of our knowledge, this is the largest case series discussing conservative treatment in children with tracheobronchial injuries. In six of the eight patients, their injuries were related to endotracheal intubation. This further highlights the need for more research into intubation techniques and methods, and other ways that these iatrogenic injuries can be prevented. All eight of our patients were initially treated conservatively, and when intubation was required this consisted of bridging the defect with an endotracheal tube distal to the lesion. We acknowledge that there are circumstances where immediate open surgical repair is necessary, but those should be the exception rather than the rule. By using initial conservative therapy, we were able to avoid surgical procedures in most of our patients. We believe that this case series provides further support that conservative management for children with tracheobronchial injuries is safe, and can avoid open procedure in most patients.
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