Conservative approach of a paediatric tracheal rupture
- 1 Department of Pediatrics, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- 2 Pediatric Surgery Service, Department of Pediatrics, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
- 3 Pediatric Intensive Care Unit; Department of Pediatrics, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal
- 4 Pediatric Intensive Care Unit; Department of Pediatrics; Lead of Pediatric Interhospital Transport System and Neonatal and Pediatric ECMO Program, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
- Correspondence to Dr Catarina Marques Duarte; catarina.m.duarte@gmail.com
Abstract
A girl was brought into the emergency room after a non-penetrating cervical trauma. On physical examination, a rapidly progressing chest subcutaneous emphysema was denoted. The child was immediately intubated and mechanical ventilation was initiated. The CT-scan revealed a rupture to the posterior wall of the trachea and a pneumomediastinum. The child was transferred to the paediatric intensive care unit. A conservative approach was chosen, including tracheal intubation as a bypass through the tracheal injury, sedation to reduce the risk of further tracheal trauma and prophylactic antibiotic therapy. Twelve days after the incident, a bronchoscopy demonstrated the integrity of tracheal mucous and the child was successfully extubated. Three months after hospital discharge she was asymptomatic. In this clinical case, the conservative approach presented a successful outcome, avoiding the risks associated with surgery.
Background
Traumatic tracheal rupture is a rare but life-threatening injury.1 2 It usually happens following a blunt trauma, but other mechanisms can induce tracheal ruptures such as iatrogenic injury secondary to stenosis dilation, rigid bronchoscopy or tracheal intubation.3
The clinical presentation could be insidious or fulminate, ranging from respiratory distress to respiratory collapse in consequence of airway obstruction. The most common signs of tracheobronchial injury are subcutaneous emphysema, respiratory distress, pneumothorax and pneumomediastinum.3 4
The study of images, through both X-ray and CT is important to confirm the diagnosis. Rigid laryngoscopy and bronchoscopy are the standard methods for viewing the airway, although they might not be available at the emergency room.5
The management of tracheal rupture is controversial. Early surgical intervention to repair tracheal rupture is referred to as the cornerstone treatment. However, recent case studies have supported the use of more conservative therapies in managing paediatric tracheal injuries, thus avoiding the inherent risks associated with an open surgery.4 6
The aim of this article is to describe a paediatric traumatic tracheal rupture treated with the use of a conservative approach with a successful outcome.
Case presentation
A previously healthy toddler girl was brought into the emergency room after a non-penetrating cervical trauma, as a result of a direct accidental fall on a piece of wooden furniture. On arrival of the paramedics, the child presented vomiting and a massive subcutaneous emphysema, which extended from the face to the entire chest area. In the hospital emergency room, the physical examination revealed hypoxaemia (SpO2 90%) with oxygen flow of 15 L/min, an ecchymosis on the neck (measuring 2 mm width) and a rapidly progressing subcutaneous emphysema extending to the upper limbs. Vital signs were stable. A nasal fibroscopy performed in the emergency room revealed no lesions to the larynx. Tracheal intubation and mechanical ventilation were immediately performed considering the rapid progression of subcutaneous emphysema with a risk of upper airway obstruction. The tracheal intubation was performed with an endotracheal tube placed 1.2 cm from the carina, with the cuff (inflated with 25 cmH2O) at the level of tracheal injury. After this procedure, the subcutaneous emphysema improved.
Investigations
On the day of arrival at the emergency unit, a maxillofacial and chest CT-scan were undertaken. The result was a subcutaneous emphysema spreading from the face down to the chest, including the extraconal intraorbital compartment and a pneumomediastinum. A rupture to the posterior wall of the trachea (less than 0.5 cm) was described 4.5 cm from the carina, at the transition between cervical and thoracic tracheal portions, above the sternal notch (figures 1 and 2). Blood tests were unremarkable.
CT in a coronal plain. Subcutaneous emphysema is visible in cervical and thoracic regions (arrow).
CT in a transversal plain. On the left figure, abundant subcutaneous emphysema is present in thoracic regions (black arrow) and an extended pneumomediastinum (white arrow) is visible. On the right figure, a tracheal rupture in posterior wall is signalised by the arrow.
Treatment
The patient was transferred to paediatric intensive care unit (PICU) for further treatment.
Considering the risk of mediastinitis, she received 10 days of intravenous amoxicillin and clavulanic acid. During her time in PICU, blood tests revealed an elevation of the inflammatory markers, with a maximum of C reactive protein of 12.3 mg/dL, attributed to a respiratory infection with Haemophilus influenzae isolated in the bronchial secretions, sensitive to the previously prescribed antibiotic treatment.
Mechanical ventilation was maintained with tidal volume 8 mL/kg, positive end-expiratory pressure of 5 cmH2O and a fraction of inspired oxygen of 50%, which allowed her to maintain SpO2 over 96%. To minimise tracheal injury and to promote tracheal healing, the cuff pressure of the endotracheal tube was often adjusted and sedative agents were prescribed. A considerable reduction in subcutaneous emphysema was visible during this period. Specific subcutaneous emphysema therapy was not required. On the 12th day of mechanical ventilation, a bronchoscopy was done through endotracheal tube, which was removed during the procedure allowing visualisation of the whole trachea up to the vocal cords, confirming the integrity of the mucosa. The child was successfully extubated on that day.
During mechanical ventilation, high doses of opioids and benzodiazepines for sedation were required. Considering the duration and the cumulative doses of these drugs, the child developed withdrawal symptoms, after being weaned from the infusions. The withdrawal symptoms were monitored with the withdrawal assessment tool (WAT-1) and it achieved a maximum of 6 points. The child was put back onto a course of opioids and benzodiazepines, and was gradually weaned off the drugs, while at the same time being given a clonidine infusion.
During the period in PICU, the patient received enteral nutrition by a nasogastric tube through which continuous feeding with infant formula was performed with tolerance.
Outcome and follow-up
The patient was transferred to the paediatric ward on day 19 of admission, where she continued to receive the clonidine infusion. Withdrawal symptoms persisted throughout the period of treatment and physical rehabilitation, gradually subsiding.
She was discharged from the hospital on day 21 and presented no signs of subcutaneous emphysema or respiratory distress.
Follow-up medical appointments were booked, the first within 1 week of discharge, and the second within 3 months.
In this follow-up period, the child was asymptomatic and did not present any respiratory distress or withdrawal symptoms.
Discussion
Tracheal rupture is a rare injury with a reported incidence of around 0.03%–0.12% with high morbidity and mortality.6 7 Tracheal rupture can occur due to a penetrating injury or blunt trauma. In most cases, the rupture occurs during an iatrogenic procedure, such as an endotracheal intubation. Tracheal injuries from blunt trauma, as reported in this case study, are a rare traumatic mechanism which could be explained by a trauma to the chest while the glottis is closed or by a tracheal hyperextension.4 6 7
The hallmark of airway lesion is subcutaneous emphysema, as was the case in our clinical study. On physical examination other signs may be present, namely cervical ecchymosis, respiratory distress and a decrease or absence of breathing sounds, which could be indicative of a pneumothorax or pneumomediastinum complication.6 8
The diagnosis of tracheal rupture requires a high level of suspicion. Chest X-rays can show subcutaneous emphysema and its progression, pneumothorax and pneumomediastinum.8 CT-scans are an important way to check for tracheal rupture and any pulmonary complications. Bronchoscopy is the standard method for identifying the exact location of the airway injury.6 8 In the present case, a maxillofacial and chest CT scan were undertaken for the diagnosis of tracheal injury while a bronchoscopy was important to evaluate the clinical response to a more conservative treatment.
Surgical management of tracheal injury is associated with long-term morbidity and high mortality.9 Recent case studies have shown that a conservative approach, without surgical intervention, is often recommended. This strategy may include paralytic agents and sedation, thus promoting the healing of a tracheal injury, as well as antireflux and antimicrobial medications. Intubation is often required and bypasses the actual tracheal injury site, preventing subcutaneous emphysema, pneumothorax and pneumomediastinum progression. Being intubated, the glottis is open, preventing an increase in intratracheal pressure. Other measures should be associated to avoid iatrogenic injury to the subglottic area, such as regular assessment of cuff pressure, limitation of the patient movement through sedative and neuromuscular blocking agents.6 The duration of the mechanical ventilation depends on the length of the tracheal injury.6 Currently, no guidelines are available about the minimum duration of intubation required for tracheal healing. In the literature, the intubation time range from 3 to 10 days.8 Some reports suggest that after the reabsorption of the subcutaneous emphysema, extubation may be performed.8
Conti et al describe a group of 30 adult patients all presenting penetrating tracheal injury, mostly treated using a conservative approach. Of these, only two patients required an initial surgery.10 Another article with a group of children published by Wood et al, described eight cases of non-penetrating traumatic tracheal injuries treated using a conservative approach.6
Some authors considered that in the case of stable vital signs, with an absence of pneumomediastinum and subcutaneous emphysema progression, adequate mechanical ventilation and an absence of sepsis, a conservative approach should be undertaken. Any type of respiratory distress, tracheal rupture measuring 1 cm or more, or haemodynamic instability, requires surgical intervention.5 6 11 12
In this case study, the child was intubated in the emergency room to avoid the progression of the subcutaneous emphysema, preventing the airway from collapsing. An endotracheal tube with cuff was placed at the level of the tracheal rupture, with periodic adjustment of the cuff pressure, promoting tracheal healing. During mechanical ventilation, a clinical improvement was visible with a reduction of the subcutaneous emphysema. A high dose of sedative was required to avoid further injury from the movements of the endotracheal tube. Following 12 days of a conservative approach, a bronchoscopy was carried out, which showed an integrity of the tracheal mucous and the successful healing of the tracheal rupture.
Tracheal stenosis is one of the possible long-term complication of a ruptured airway. Treatment using a conservative approach is not associated with a higher risk of stenosis.6 8 In this particular case, we followed a conservative approach, without any complications following the incident.
In conclusion, tracheal rupture represents both a diagnosis and a management challenge, with few case reports and no clinical guidelines to follow. Although surgical treatment is chosen in some cases, a conservative approach could be the best solution for uncomplicated tracheal ruptures, such as the one presented.
Learning points
-
A traumatic tracheal rupture is a rare injury that may occur following a non-penetrating neck trauma.
-
It could be a life-threatening injury with a rapid respiratory collapse. Early diagnosis is essential to improving the outcome.
-
A conservative approach should be considered in non-penetrating traumatic tracheal injuries, in children, thus avoiding the complications of a surgical procedure.
Ethics statements
Patient consent for publication
Footnotes
-
Twitter @Catarina Marques Duarte
-
Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: Francisco Abecasis devised the main conceptual ideas. Catarina Marques Duarte wrote the manuscript with support from Sofia Almeida, Elizabete Vieira, Francisco Abecasis. All authors provided critical feedback and helped shape the manuscript.
-
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
-
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
-
Competing interests None declared.
-
Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.
References
Use of this content is subject to our disclaimer