Pediatric emergency medicine trisk 4070 4070
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Many inflammatory processes within the trachea are controlled with antibiotics
and respiratory care without airway manipulation or surgical intervention.
Treatment in these cases includes the administration of humidified oxygen and
inhaled racemic epinephrine, combined in some cases with the administration of
oral, intramuscular, or intravascular dexamethasone. Although laryngoscopy and
tube delivery may be difficult in patients with epiglottitis, an appropriately placed
endotracheal tube fully stabilizes most patients since the inflammation is
supraglottic with no tracheal or lower respiratory tract involvement. Rarely is
intubation necessary for more than 24 to 48 hours in these patients, after which
antibiotics have begun to reduce the swelling associated with infection. In a
patient with viral or bacterial tracheitis, however, intubation for more than 24 to
48 hours may produce tracheal injury and ulceration.
Tracheomalacia
Tracheomalacia, sometimes complicating lung disease of prematurity, is a
relatively common cause of airway obstruction. It is characterized by a floppy
trachea that collapses during expiration when the intrathoracic trachea is
compressed by the positive intrathoracic pressure. It can be caused by intrinsic
tracheal defects, extrinsic compression by surrounding structures, or from
prolonged positive pressure ventilation. It commonly occurs in association with
TEF repair (see TEF below).
Clinical Recognition
The clinical presentation of tracheomalacia depends on the severity and location
of obstruction with more severe lesions presenting earlier in infancy. When the
intrathoracic trachea is involved, patients often have expiratory wheeze that may
be hard to distinguish from asthma. Intrathoracic involvement is more likely to
cause stridor, which can progress to occur at rest. Patients often have cough and
evidence of respiratory distress. They may present with recurrent respiratory
infections and episodes of severe obstruction and respiratory failure.
Tracheomalacia is typically diagnosed using bronchoscopy during spontaneous
respiration, which demonstrates the characteristic tracheal collapse with
expiration. Although dynamic imaging studies may be useful, standard imaging
modalities are typically not helpful in making this diagnosis.
Management
In general, children who are otherwise healthy will have resolution of symptoms
by about 1 year of age as the cartilaginous tracheal structures mature. During
episodes of acute illness, however, these children can present with severe work of
