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\begin{document}

\title{Tracheostomy related tracheal tears in pediatrics}



\author[1]{Mazyad Alenezi}%
\author[2]{Ali Alsudays}%
\author[3]{Sultan  Alanazy}%
\author[2]{Eman Almashharawi}%
\author[2]{Samir Bawazir}%
\affil[1]{Qassim University College of Medicine}%
\affil[2]{Prince Sultan Military Medical City}%
\affil[3]{Unaizah College of Medicine at Qassim University}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Tracheostomy related tracheal tear is a serious complication that may
follows surgical or percutaneous tracheostomy. Pediatric populations
carry higher risk because of the anatomical differences. It needs
immediate diagnosis as may leads to life threatening outcomes such as
pneumothorax, respiratory distress, extensive subcutaneous emphysema and
pneumomediastinum. The best way to diagnose and discover tracheal tear
is by tracheobronchoscopy. If the diagnosis established prompt
management and treatment should be performed. Objective The aim of this
article is to review tracheal tears and to help in their diagnosis and
management with assistance of clinical and radiological findings.
Methods and Materials A literature review of PubMed , ovid Medline and
cochrane collaboration databases was done using the terms pediatric ,
tracheostomy , tracheal tear. Discussion Tracheostomy related tracheal
tear occurs infrequently and less commonly than intubation related
tracheal tear. Mostly it is related to tracheostomy placement, using
cuffed tubes and overinflation of the cuff or the tear directly follows
traumatizing tracheostomy tube introducer insertion. The tear due to
tracheostomy mostly located proximal to carina and distal to insertion
of point of tracheostomy. Symptoms and complications of the tear may
occur intraopertivly or postoperatively(5). Gold standard method for
diagnosis will be established by flexible or rigid tracheobronchoscopy
which helps in determining the site, size, extension of the tear and its
location with respect to the carina that are essential to document.
Imaging studies like CT scan which also helps in establishing the
diagnosis of tear and some of it is complications such as pneumothorax,
pneumonia, pneumomediastinum and mediastinitis. Treatment can be
conservative for small uncomplicated wound in stable patient. For larger
complicated tears and unstable patient surgical treatment is the gold
standard. Conclusion Treatment choices depend on tear site , size,
extension of the tear and the status of the patient. Conservative
management is sufficient for stable patients with small tears . On the
other hand , surgical management is essential for unstable patients and
large complicated wounds.%
\end{abstract}%



\sloppy


\textbf{Abstract:}

Tracheostomy related tracheal tear is a serious complication that may
follows surgical or percutaneous tracheostomy. Pediatric populations
carry higher risk because of the anatomical differences. It needs
immediate diagnosis as may leads to life threatening outcomes such as
pneumothorax, respiratory distress, extensive subcutaneous emphysema and
pneumomediastinum. The best way to diagnose and discover tracheal tear
is by tracheobronchoscopy. If the diagnosis established prompt
management and treatment should be performed.

\textbf{Objective}

The aim of this article is to review tracheal tears and to help in their
diagnosis and management with assistance of clinical and radiological
findings.

\textbf{Methods and Materials}

A literature review of PubMed , ovid Medline and cochrane collaboration
databases was done using the terms pediatric , tracheostomy , tracheal
tear.

\textbf{Discussion}

Tracheostomy related tracheal tear occurs infrequently and less commonly
than intubation related tracheal tear. Mostly it is related to
tracheostomy placement, using cuffed tubes and overinflation of the cuff
or the tear directly follows traumatizing tracheostomy tube introducer
insertion. The tear due to tracheostomy mostly located proximal to
carina and distal to insertion of point of tracheostomy. Symptoms and
complications of the tear may occur intraopertivly or
postoperatively(5). Gold standard method for diagnosis will be
established by flexible or rigid tracheobronchoscopy which helps in
determining the site, size, extension of the tear and its location with
respect to the carina that are essential to document. Imaging studies
like CT scan which also helps in establishing the diagnosis of tear and
some of it is complications such as pneumothorax, pneumonia,
pneumomediastinum and mediastinitis. Treatment can be conservative for
small uncomplicated wound in stable patient. For larger complicated
tears and unstable patient surgical treatment is the gold standard.

\textbf{Conclusion}

Treatment choices depend on tear site , size, extension of the tear and
the status of the patient. Conservative management is sufficient for
stable patients with small tears . On the other hand , surgical
management is essential for unstable patients and large complicated
wounds.

\textbf{Keywords}

Tracheal tear, tracheostomy, pediatric.

\textbf{Key points}

This article is non-systematic review literature about tracheostomy
related tracheal tear in pediatrics.

There is paucity of description of this condition in pediatrics in
literature.

The article may help clinician to recognize this condition
intraoperatively or postoperatively with early recognition of clinical
and radiological finding.

Diagnosis of this condition require high level of suspicious index and
background of it. Delayed diagnosis may cause significant morbidity and
mortality.

The management range from simple conservative to complex operative
intervention.

\textbf{Background:}

Tracheal tear is a rare but potentially fatal complication of thoracic
or neck injuries, spontaneously or iatrogenically during intubation and,
less commonly, bronchoscopy and surgical and percutaneous tracheostomy
(1,2). The aim of this article is to review tracheal tears and to help
in their diagnosis and management with assistance of clinical and
radiological findings.

\textbf{Methods and Materials}

A literature review of PubMed , ovid Medline and cochrane collaboration
databases was done using the terms pediatric , tracheostomy , tracheal
tear.

\textbf{Discussion}

In the pediatric population, intubation-related tracheal tear due to a
large endotracheal size is the most common mechanism of airway injury,
so selection of appropriate tube size is essential (3,4). Furthermore,
frequent manipulation of the tube without overinflation or deflation and
intubation performed by inexperienced clinicians are common causes of
tracheal tears (5).

Tracheostomy-related posterior tracheal tears occur infrequently and are
less commonly than intubation-related tracheal tear. They usually occur
during tracheostomy placement, use of cuffed tubes, and overinflation of
the cuff or tear following tracheal trauma during introducer insertion
(6,7,8). Tracheostomy-related tears are is mainly located proximal to
the carina and distal to the insertion point of the tracheostomy.(3,9)
Pediatric patients are at higher risk of iatrogenic tracheal tears than
adults due to anatomical differences: weaker intercartilaginous
membrane, higher cartilage elasticity, and smaller airway lumen. In
addition, the mortality rate in pediatric patients after iatrogenic
tracheal tears is as high as 75\%, so the selection of the appropriate
tube size is essential (3). Short thick neck, kyphoscoliosis, and
emergency cases with difficult intubation increase the risk of tracheal
tears in pediatric patients (1,7,9).

Iatrogenic trachel lacerations may present immediately as impaired
ventilation or later in the postoperative period with the complications
of compressive pneumothorax, pneumomediastinum, or extensive
subcutaneous emphysema, especially during retching or coughing or in
mechanically ventilated patients (1,10). Furthermore, tracheobronchial
tears can lead to many other complications such as respiratory distress,
mediastinitis, tracheal stenosis, recurrent nerve injury, fistula, and
abscess. The gold standard for diagnosis is flexible or rigid
tracheobronchoscopy, which helps determine the site, extension, and
location of the tear with respect to the carina. Imaging studies such as
computed tomography (CT) can help identify complications such as
pneumothorax, pneumonia, pneumomediastinum, and mediastinitis. Chest and
lateral neck radiographs are helpful too, but they have a false negative
rate reaching 10\% (1,2,5,9,10). In addition, esophagoscopy is essential
to rule out esophageal injuries (3,10). In 88\% of cases, tears are
diagnosed intraoperatively because of emphysema in the mediastinum or
impaired ventilation (11).

Treatment can be conservative or surgical. Conservative treatment is
indicated for mechanically ventilated patients and hemodynamically
stable patients with uncomplicated and small (\textless{}3 cm) tears, no
protrusion of mediastinal structures into the tracheal lumen, and only
mild emphysema. Conservative treatment includes the insertion of
longer/adjustable-length tracheostomy tubes or endotracheal tube,
preferably under endoscopic guidance with an appropriate tube size,
which is placed distal to the tear site with continuous cuff pressure
measurement. If the tear is close to the carina, positioning the cuff
distal to the tracheal tear is challenging, so tube placement should be
performed under endoscopic guidance to ensure proper tube placement,
along with continuous cuff pressure measurement to avoid tear
enlargement (1,5,10,12-14). Furthermore, the approach to mechanical
ventilation is important as positive pressure ventilation can exacerbate
the injury. On the other hand, ventilation helps the tear to
spontaneously collapse, thus supporting tear healing. All this should be
done under the cover of a broad-spectrum antibiotic to reduce the risk
of infection (1,3,10). Surgical treatment is preferred for patients with
large or complicated tears, tracheal avulsion, and extensive emphysema
and those who are unstable during ventilation. Surgical repair should be
performed as soon as possible to decrease the risk of complications. The
choice of surgical approach should be guided by the anatomical site of
the tear. Using the tracheostomy opening is highly recommended because
the incision already exists and the laceration is almost always proximal
to the carina and rarely extends beyond it (1). Deganello et al.
described surgical repair of a large proximal tracheal tear that ended
above the carina in an adult patient through an extended tracheotomy
opening technique with interrupted sutures using a thoracoscopic needle
holder (1). Welter et al. described a repair of similar tear with no
surgical access using an optical needle holder with interrupted sutures
through rigid bronchoscopy (13). Chaaban et al. treated a large tear in
a surgically unfit tracheostomized adult patient using a customized
silicone stent, which was inserted under bronchoscopy guidance to bridge
the tear end. Then, at the level of the tracheostomy site, an anterior
window was made in the stent to insert the tracheostomy tube through the
stent (14). If the tear extends up to the bronchial tree, thoracotomy is
required. Tears involving the carina, right bronchial tree, and proximal
region of the left main bronchus necessitate right thoracotomy. Left
thoracotomy is required if the injuries lie in the left main bronchus
near the lung hilum and left bronchial tree (5). If significant tracheal
mucosa injury and concern of stenosis are present, tracheal segment
resection with end-to-end anastomosis may be performed. In addition,
sealing the tear at the anterior esophageal wall can help secure the
tear. After the repair of the tear, a soft noncuffed tube should be
used. If a cuffed tube is used, the cuff pressure need to be monitored.
To decrease peristaltic movement, nasogastric tube should be inserted
for at least 1 week. For both surgical and nonsurgical treatment,
multiple follow-up chest and lateral neck radiography is needed, as well
as regular serial endoscopic examinations, such as daily bedside
fiberoptic endoscopy and bronchoscopy for a few days. During assessment,
the endotracheal or tracheostomy tube should be carefully retracted to
check for healing, proper tube placement at a suitable level, and
evidence of stenosis or tracheoesophageal fistula (1,9,11).

\textbf{Conclusion:}

Treatment of iatrogenic tracheal tears choices depend on tear site,
size, and extension of the tear and patient's hemodynamic status.
Conservative management is sufficient for stable patients with small
tears, whereas surgical management is essential for unstable patients
and those with large or complicated tears. Tracheostomy-related tears
are often proximal to the carina, so the tracheostomy opening can be
used during repair surgery. Thoracotomy is required if the tear involves
the bronchial tree.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{References:}

1. Deganello A, Sofra MC, Facciolo F, Spriano G. Tracheotomy-related
posterior tracheal wall rupture, trans-tracheal repair. Acta
Otorhinolaryngol Ital Organo Uff Della Soc Ital Otorinolaringol E Chir
Cerv-facc. 2007;27(5):258--62.

2. Schedlbauer E-M, Todt I, Ernst A, Seidl RO. Iatrogenic tracheal
rupture in children: A retrospective study. The Laryngoscope.
2009;119(3):571--5.

3. Cunningham LC, Jatana KR, Grischkan JM. Conservative management of
iatrogenic membranous tracheal wall injury: a discussion of 2 successful
pediatric cases. JAMA Otolaryngol Neck Surg. 2013;139(4):405.

4. Holzki J, Laschat M, Puder C. Iatrogenic damage to the pediatric
airway Mechanisms and scar development. Pediatr Anesth. 2009;19:131--46.

5. Panagiotopoulos N, Patrini D, Barnard M, Koletsis E, Dougenis D,
Lawrence D. Conservative versus surgical management of iatrogenic
tracheal rupture. Med Princ Pract. 2017;26(3):218--20.

6. Cipriano A, Mao ML, Hon HH, Vazquez D, Stawicki SP, Sharpe RP, et al.
An overview of complications associated with open and percutaneous
tracheostomy procedures. Int J Crit Illn Inj Sci. 2015;5(3):179--88.

7. Douglas W, Flabouris A. Surgical emphysema following percutaneous
tracheostomy. Anaesth Intensive Care. 1999;27:69--72.

8. D SMETS,~H SPAPEN,~M DILTOER,~M NOPPEN,~J LAMOTE,~R SACR\selectlanguage{ngerman}É,~L
HUYGHENS. (1999)~Percutaneous tracheotomy in critically ill patients:
prospective evaluation of two different techniques.~Clinical Intensive
Care~10:5, pages 191-194.

9. Kaylie DM, Wax MK. Massive subcutaneous emphysema following
percutaneous tracheostomy. Am J Otolaryngol. 2002;23(5):300--2.

10. Deja M, Menk M, Heidenhain C, Spies CD, Heymann A, Weidemann H,
Branscheid D, Weber-Carstens S. Strategies for diagnosis and treatment
of iatrogenic tracheal ruptures. Minerva Anestesiol. 2011
Dec;77(12):1155-66. Epub 2011 May 20. PMID: 21602752.

11. Massard G, Rougé C, Dabbagh A, Kessler R, Hentz JG, Roeslin N, Wihlm
JM, Morand G. Tracheobronchial lacerations after intubation and
tracheostomy. Ann Thorac Surg. 1996 May;61(5):1483-7. doi:
10.1016/0003-4975(96)00083-5. PMID: 8633963.

12. Sidana S, Srinivasan D, Oloyede D. Tracheal tear following elective
tracheostomy. Br J Oral Maxillofac Surg. 2009 Apr;47(3):243-4. doi:
10.1016/j.bjoms.2008.09.005. Epub 2008 Oct 31. PMID: 18977055.

13. Welter S, Jacobs J, Krbek T, Halder R, Stamatis G. A new endoscopic
technique for intraluminal repair of posterior tracheal laceration. Ann
Thorac Surg. 2010;90(2):686--8. doi:10.1016/j.athoracsur.2009.08.056

14. Chaaban S, Simoff M, Ray C, Diaz-Mendoza J. Posterior tracheal
laceration treated with a stent. Ann Am Thorac Soc. 2017;14(7):1224--6.
doi:10.1513/AnnalsATS.201611-937CC

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