A 500-gram, 23-week premature baby is born and immediately intubated. There was some difficulty with intubation, but the patient remained hemodynamically stable. Chest radiographs immediately following intubation and four hours later are shown below.

[center]postintubation CXR 1

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[center]postintubation (after 4 hours) CXR 2

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Over the next 24 hours, patient remained clinically stable on a high frequency oscillator and the following chestradiograph is obtained,

 

[center]postintubation (after 24 hours) CXR 3

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[size=20px]The best next step in management of this infant with pneumomediastinum is

 

A continued observation.

 

B right mainstem intubation.

 

C place a chest tube.

 

D right thoracotomy.

 

E median sternotomy.[/size]

A

think again my dear

C

think again my dear

A

A

A

think again my dear

think again my dear

think again my dear

A...

If the child remains stable

think again my dear

D

D

correct

 

Given the history of extreme prematurity and difficult intubation this patient likely sustained a tracheal injury. The first radiograph shows the endotracheral tube (ETT) to be right at the carina with minimal pneumomediastinum. As the ETT is pulled back, the pneumomediastinum became larger. Despite changes in the ventilation strategy, the pneumomediastinum continued to increase. Further observation is not appropriate given the progression of the pneumomediastinum.

 

Iatrogenic tracheal injuries can occur with difficult and traumatic intubations. A common presentation is posterior pneumomediastinum as seen in the radiographs above. Management is largely based on the condition and size of the patient. Intubation while under general anesthesia prior to surgery is a common scenario for iatrogenic tracheal injuries. In such instances when tracheal injuries are suspected, bronchoscopy should be performed to determined the location and extent of the injury. In stable patients, small injuries can be managed with extubation and close observation. If the injury is in the proximal trachea, the ETT can be positioned to cover the injury. Repeat bronchoscopy in one week will often demonstrate complete healing of the injury and the patient can be safely extubated. In some cases, bronchoscopy may not be possible due to the small patient size.

 

Observation is the first step in management of premature neonates with suspected tracheal injury. If tolerated, patients should be extubated to avoid positive pressure ventilation. If unable to extubate, then ventilation with the high-frequency oscillator should be attempted. In this case, the pneumomediastinum significantly increased despite conservative management including ventilation changes and surgical intervention is required. The best approach for tracheal injuries is via right thoracotomy as the entire trachea can be exposed. Injuries can often be primarily repaired and reinforced with a pleural flap.

 

In premature infants, single lung ventilation via right mainstem intubation is typically not tolerated. Chest tube placement may be considered in cases progressing to tension pneumothorax, otherwise should be avoided. Exposure via median sternotomy will not be adequate for repair.

 

Although tracheal injuries are rare and only case reports are available, pediatric surgeons should be familiar with the management of this condition.