Tracheal Tracheal stenosisstenosis

Complete tracheal ringsComplete tracheal rings

Tracheal Tracheal stenosisstenosis and complete and complete

tracheal ringtracheal ring

Does mode of ventilation matter?Does mode of ventilation matter?

Spontaneous Paralyzed

Take home: Avoid paralytics!

SpontaneousSpontaneous ParalyzedParalyzed

Take home: Avoid paralytics!Take home: Avoid paralytics!

Evaluation Evaluation

� Chest X-ray (AP/lateral)

� Fiberoptic bronchoscopy

� Echocardiogram for co-existing congenital cardiac disease

� Direct laryngoscopy and bronchoscopy

� Imaging study

� MRI***

� CT with 3D reconstruction

� Chest X-ray (AP/lateral)

� Fiberoptic bronchoscopy

� Echocardiogram for co-existing congenital cardiac disease

� Direct laryngoscopy and bronchoscopy

� Imaging study

� MRI***

� CT with 3D reconstruction

Which study should be done?Which study should be done?

MRI

� Long scan time

� Requires IV GA

� +/- intubation

� Infant with airway

issues should not be

in the MRI

� No good

MRIMRI

�� Long scan timeLong scan time

�� Requires IV GARequires IV GA

�� +/+/-- intubationintubation

�� Infant with airway Infant with airway

issues should not be issues should not be

in the MRIin the MRI

�� No goodNo good

CT scan

� Fast

� Effective

� No sedation needed

� White tape

CT scanCT scan

�� FastFast

�� EffectiveEffective

�� No sedation neededNo sedation needed

�� White tapeWhite tape

“Marked tracheal narrowing extending from just above the thoracic inlet into the proximal main stem bronchi bilaterally”

“Marked tracheal narrowing extending from just above the thoracic inlet into the proximal main stem bronchi bilaterally”

Management optionsManagement options

�� Do nothingDo nothing

�� Balloon dilation/Balloon dilation/stentingstenting

�� Tracheal resection of Tracheal resection of stenoticstenotic segment segment and primary and primary anastomosisanastomosis

�� Long tracheal incision and pericardial Long tracheal incision and pericardial patch graftpatch graft

�� Slide Slide tracheoplastytracheoplasty

�� With or without CPB supportWith or without CPB support

EurEur J J CardiothoracCardiothorac Surg. 2006 Jun;29(6):991Surg. 2006 Jun;29(6):991--66

Nasal CPAP + Nasal CPAP + HelioxHeliox

� 79% Helium + 21% Oxygen

� Airway resistance dependent on airway diameter and density of inspired gases

� Helium is a lower density gas than Nitrogen

� Airway resistance is reduced due to the lower density inspired gases

� Reduced WOB and mechanical energy to breathe

� Rx: upper airway obstruction, asthma bronchiolitis croup

�� 79% Helium + 21% Oxygen79% Helium + 21% Oxygen

�� Airway resistance dependent on airway Airway resistance dependent on airway diameter and density of inspired gasesdiameter and density of inspired gases

�� Helium is a lower density gas than NitrogenHelium is a lower density gas than Nitrogen

�� Airway resistance is reduced due to the lower Airway resistance is reduced due to the lower density inspired gasesdensity inspired gases

�� Reduced WOB and mechanical energy to Reduced WOB and mechanical energy to breathebreathe

�� Rx: upper airway obstruction, asthma Rx: upper airway obstruction, asthma bronchiolitisbronchiolitis croupcroup

NonNon--operative management of operative management of

complete tracheal ringscomplete tracheal rings�� 10 children complete tracheal rings confirmed on 10 children complete tracheal rings confirmed on

bronchoscopybronchoscopy (observed for 1 to 12 years)(observed for 1 to 12 years)�� 5 minimally symptomatic/asymptomatic 5 minimally symptomatic/asymptomatic --

bronchoscopicbronchoscopic evidence of progressive airway growth: evidence of progressive airway growth: no no tracheoplastytracheoplasty

�� 2 worsening symptoms 2 worsening symptoms -- bronchoscopicbronchoscopic evidence evidence minimal airway growth: minimal airway growth: tracheoplastytracheoplasty

�� 3 clinically observed: may require 3 clinically observed: may require tracheoplastytracheoplasty

�� Not all patients with complete tracheal rings Not all patients with complete tracheal rings require require tracheoplastytracheoplasty

�� Period of observation to monitor airway growthPeriod of observation to monitor airway growth

Arch Arch OtolaryngolOtolaryngol Head Neck Surg. 2004;130(4):450Head Neck Surg. 2004;130(4):450--22

StentsStents

Resection with endResection with end--end end

anastomosisanastomosis

Pericardial Pericardial tracheoplastytracheoplasty

Slide Slide tracheoplastytracheoplasty

ECMOECMO

�� VAVA�� Support pulmonary and cardiac functionSupport pulmonary and cardiac function

�� CannulatingCannulating common carotid artery common carotid artery

�� Risk of emboliRisk of emboli

�� VV and double lumen VVVV and double lumen VV�� Support adequate gas exchange Support adequate gas exchange

�� Minimal risk of arterial eventsMinimal risk of arterial events

�� Fraction of recently infused blood reFraction of recently infused blood re--circulates circulates back to ECMO circuitback to ECMO circuit