Pediatric emergency medicine trisk 4069 4069
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Tracheal obstruction can be caused by a variety of mechanical, infectious, and
congenital abnormalities. Clinicians must rapidly assess the cause of obstruction
while working toward stabilization of the airway. Surgical causes of obstruction
require prompt consultation and coordination of care.
Clinical Considerations
Clinical Recognition. Tracheal compromise produces symptoms that vary from
mild to severe, depending on the degree of obstruction present. When symptoms
are mild, an underlying cause may not be evident. Occasional episodes of
respiratory infection that are believed to result from croup or bronchiolitis may be
the only symptom. Stridor, wheezing, or harsh barky cough occurs in patients
with more significant obstruction, and a history of frequent hospitalizations for
respiratory compromise may be obtained.
Severe tracheal compromise is usually manifested by a history of stridor at rest.
Progressive cyanosis and apneic episodes may occur. On examination, a child
with obstruction caused by extrinsic compression often has wheezing or stridor
throughout the respiratory cycle. In contrast, a patient with the floppy trachea of
tracheomalacia often wheezes only during expiration.
Radiographic evaluation of the stable patient should begin with PA and lateral
chest radiographs, ideally obtained at full inspiration and again at full expiration.
Lateral radiographs of the neck may be useful in showing an edematous epiglottis
in patients with suspected epiglottitis. Mass lesions will require cross-section
imaging (e.g., computed tomography [CT]) for evaluation. Bronchoscopy is often
indicated to evaluate obstructive lesions, whether in the lumen, the wall, or
extrinsic to the wall of the trachea.
Management. If the patient has a life-threatening airway obstruction, he or she
should receive airway management as outlined in Chapters 7 A General
Approach to the Ill or Injured Child and 8 Airway . A coordinated effort between
the emergency department (ED) care team, the surgeon, and the anesthesiologist
or critical care physician may be necessary to establish an airway by endotracheal
intubation, bronchoscopy, or tracheotomy. Intubation of the airway to within a
short distance of the carina supports most patients with critical obstruction
secondary to lesions extrinsic to the trachea or within the tracheal wall. Such
patients require admission to an intensive care unit with ventilator capability.
Lesions within the lumen will likely require endoscopic management in an
operating room, and early involvement of an experienced surgeon is
recommended.
