Pediatric Intubation

CLINICAL CONDITIONS INVOLVING DIFFICULT INTUBATION

When dealing with pediatric intubation and post-intubation sequelae one must always be concerned with stridor. To visualize a stridorous child at the University of Minnesota web site click here.

Try this site for peds airway case studies...Airway case studies

Stridor:

As noted stridor can have many etiologies. In the case of the infant seen at the UMN site, the stridor is due to tracheobroncho-malacia, a state in which soft tracheal cartilage does not provide enough support to the airway during changes in intra and extra thoracic pressure associated with normal breathing. This is not uncommonly found in children with chronic illness, and can be associated with congenital heart disease and tracheo-esophageal fistulas. A variety of techniques have been employed to improve airway malacia, including pexy procedures in which the aorta is tacked to the anterior chest wall to relieve vascular compression. Airway stents are used at some institutions, but these have problems with the potential to erode into large blood vessels, and are notoriously difficult to remove when no longer needed.

With time, good health and good nutrition, these patients can lay down enough cartilage to overcome their severe malacia, but this can take a few years. In some cases a temporizing tracheostomy is placed to allow positive pressure ventilation until enough time has passed to allow for adequate growth.

Croup:

Croup is a more common cause of stridor. Click on the link below to see a sequence of both quiet and noisy breathing in a patient with croup and sub-glottic stenosis at the University of Minnesota pediatric website. A stridorous infant can have marked sternal retractions. Although present during quiet breathing, worsen when the patient is agitated. Stridor can be worse on inspiration This suggests an abnormality of the airway outside of the thorax, as pressures on the airway during inspiration would tend to open up the trachea and decrease the likelihood of stridor. We have seen two older children with human papillovirus (HPV) that has required frequent laser vaporization treatments with marked stridor pre and postop. One case has required tracheostomy twice and has been to surgery fifty times and counting.

Airway stents:

As noted by Parsons and Lally at Lackland Air Force Base airway stents have been tried with mixed results.

"Respiratory compromise from tracheobronchomalacia in children varies from mild to severe, but can result in either reflex apnea or death. Such severe cases may be unresponsive to aggressive medical management, and surgical options must be considered. Current surgical alternatives are limited and are associated with many potentially undesirable complications. Failure rates are often high. We present two infants with profound life-threatening airway malacia treated by endoscopic placement of a self-expanding endobronchial stent. A description of their anomaly, surgical management, and long-term care is included. The expandable stent may obviate the need for complex high-risk surgical procedures and prolonged ventilatory support."