What Is the Emergency Management of Tracheal Collapse?

Introduction:

Trachea, also known as the windpipe, runs alongside the esophagus, and it is a large tube. When there is an obstruction or blockage of airflow to the lungs due to the weakening of the trachea, then it is called a tracheal collapse. The medical term for the same is tracheomalacia. Usually, the trachea can become weak due to the walls getting weaker or because of something pressing on the trachea. The whole trachea or some parts of it can get affected. A child with tracheal collapse can have other health issues like reflux or developmental delay and a heart defect. Affected babies can exhibit amplified symptoms and breathing difficulties in case of a minor cold, which will be quite normal and less severe in unaffected children. The symptoms tend to disappear after 18 to 24 months of age in most children. In adults, it may occur due to multiple reasons, such as:

1. Bronchomalacia: If the collapsed tracheal segment branches off into the lungs, then it is called bronchomalacia.

2. Congenital Tracheomalacia: If tracheal collapse is present from birth, then it is known as congenital tracheomalacia, and it causes breathing difficulties which can be identified in one to two months after birth.

3. Acquired Tracheomalacia: It is not present since birth and is acquired by the individual after birth due to various reasons.

What Are the Causes of Tracheal Collapse?

Frequent causes of tracheal collapse include:

• Tracheal damage due to prolonged tracheostomy. Tracheostomy is an airway management procedure in which the front of the trachea is cut open through a small incision to provide an airway.

• Damage that has occurred to the esophagus or trachea during surgeries or while undergoing other medical procedures.

• Chronic infectious conditions like bronchitis. Bronchitis refers to the inflammation of the bronchial tubes.

• Patients suffering from disorders like GERD (gastroesophageal reflux disease), polychondritis, and emphysema. GERD refers to a gastric disease in which there is irritation to the esophagus due to the acid flowing back from the stomach to the esophagus. Polychondritis is a rare disorder characterized by cartilage inflammation in various body parts. Emphysema is a respiratory condition in which there is shortness of breath due to lung alveoli (air sac) damage.

• It can also occur due to irritant inhalation.

What Are the Symptoms?

The symptoms are as follows:

• Noisy breathing or breathing difficulties. This gets better by changing the baby’s position while asleep.

• Worsening breathing during crying, coughing, feeding, or when the baby catches a cold.

• Wheezing or high-pitched or rattling noise while breathing.

• Hoarseness in the voice.

• Recurrent respiratory tract infections.

• Chronic cough.

• Swallowing difficulties.

• Stridor (high-pitched sound that is produced while breathing).

How Is It Diagnosed?

Tracheal collapse can be identified in babies with the help of medical history, signs, and symptoms. Along with these, the doctor may order the following diagnostic tests to conclude:

1. An X-ray of the chest for a clear picture of the interior of the chest.

2. CT (computed tomography) scan of the chest to get a series of images across different angles and to assess any narrowing present.

3. Airway fluoroscopy to assess the trachea.

4. Pulmonary function tests (PFTs) evaluate the strength and function of the lungs.

5. Bronchoscopy to assess the bronchi or simply the lung airway.

6. A direct laryngoscopy to assess the larynx (vocal cords).

How Is a Tracheal Collapse Managed?

Tracheal collapse is treated and managed by identifying the cause. If it is due to the pressure created by a hindrance pressing on the trachea, surgery is inevitable. Otherwise, the doctor may recommend therapies if it is due to the weakening of the trachea. As the child grows, the trachea tends to get stronger, and the need for surgery is very scant. Breathing difficulty can be handled by using a humidifier to assist breathing.

• Stent: A tracheobronchial airway stent is used to open the trachea. A thin metallic expandable stent is placed into the airway with the help of a bronchoscopy.

• Physical Therapy: Non-invasive techniques such as physical chest therapy involve deep breathing exercises and also tapping lightly on the chest to enable the loosening of the mucus.

• Continuous Positive Airway Pressure: With the help of a face mask, mildly pressurized air is sent, which forces the trachea to be open and prevents a collapse.

• Tracheal Reconstruction: Surgical techniques such as tracheal reconstruction or resection are done so that the floppy pieces of cartilage are removed, and the remaining ends of cartilage are joined back.

• Tracheostomy: It is a surgical procedure to relieve obstruction in breathing. It is done by opening the anterior portion of the trachea and inserting a tube into the airway.

• Tracheoplasty: This is also a surgical procedure in which a plastic mesh or the adjacent tissue is used as support for the floppy tracheal portion to be sutured to it. This will help allow breathing and prevent collapse during breathing.

What Is the Emergency Management?

Airway compromise due to rupture is considered serious, and there is a relentless need to admit the patient to the ED (emergency department). Airway patency is the first step in the ED to help clear out secretions present in the airway. Breathing and supply of oxygen are established in the ED if they are compromised. In patients with acute symptoms like breathing difficulties, air leakage, and unstable patient conditions, intubation is done. This will help in supporting the collapsed trachea. Tracheal intubation can also cause injuries in patients with pre-existing tracheal injuries. This can be avoided by placing the cannula in the contralateral main bronchus to enable one-lung ventilation. This procedure is done with a flexible broncho-fiberscope to avoid inflicting the injury further.

For patients with difficulties in intubation or ventilation, an emergency thoracotomy procedure is done. With the guidance of operators and fingers, the cannula is placed in the opposite main bronchus. In recent years, to ensure oxygen saturation, a cardiopulmonary bypass (ECMO, extracorporeal membrane oxygenation) has been done. This procedure can be done in patients with tracheal damage that is of a wide range, and there is a complexity in repair.

Additionally, chest or mediastinal decompression and closed pleural drainage are done. Chest decompression is done by using a large bore needle into the pleural space through the chest wall to relieve any trapped air. Pleural drainage is done by a chest drain inserted into the pleural space to drain air or fluid present surrounding the lungs.

Conclusion

Tracheal collapse can be life-threatening if left untreated, and hence emergency management protocol should be followed in patients with worsening symptoms. The cause of the disease is identified to formulate a meticulous treatment plan. The choice of management, such as a surgical or non-surgical approach, is decided by the physician, depending on the severity of the condition.