G403(P) Management of severe external tracheal compression. (May 2019)

• Record Type: Journal Article
• Authors: Ramphul, M; Elloy, M; Narayanan, M
• Is Part Of: Archives of disease in childhood. Volume 104:(2019)Supplement 2
• Page Start: A163
• Page End: A164
• Publication Date: 2019-05
• Subjects: Children -- Diseases -- Periodicals; Infants -- Diseases -- Periodicals; 618.920005
• DOI: 10.1136/archdischild-2019-rcpch.389
• Languages: English
• ISSNs: 0003-9888

Abstract

Abstract : Case history: A 2 month old boy, born at term, was admitted for evaluation of episodic desaturations, unrelated to feeds. He had a background of postnatally diagnosed tracheo-oesophageal fistula (TOF) with oesophageal atresia (OA), repaired on day 5 of life. Anti-reflux medication did not abolish symptoms. Investigations: He underwent a bronchoscopy which showed significant tracheal narrowing (>90% of lumen occluded). The contour of the tracheal rings raised the suspicion of an extrinsic compression. Despite severe tracheal narrowing, the work of breathing was normal, with adequate weight gain. Overnight oximetry showed normal saturations, with desaturations below 92% occurring in less than 3% of the study time. Gas exchange was normal. At initial counselling sessions, parents were keen to avoid tracheostomy. However, whilst still an inpatient, the child developed a rhinovirus bronchiolitis and rapidly deteriorated, necessitating intensive care. A Computed Tomography (CT) angiogram with virtual CT bronchogram was performed under light general anaesthesia. This showed a complete tracheal collapse at level of the innominate artery at PEEP (positive end-expiratory pressure) of 0 cm H2O with increasing tracheal patency observed at PEEP of 10 and 15. The arteriogram phase confirmed compression of the middle-third of the trachea by the innominate artery. Results and treatment : The diagnosis of an aberrant innominate artery was made. Management options (conservative, tracheostomy or arteriopexy) were discussed at a multi-disciplinary meeting. Clinicians expressed concerns regarding the distance of parental home to the nearest emergency department, and the decompensation with an intercurrent viral illness. Following further discussion with parents, an arteriopexy was performed. Conclusions and discussion : The approach to the management of tracheomalacia or tracheal compression is dependent upon the degree of narrowing of trachea and associated symptoms. Options include a conservative approach or surgical interventions, including tracheostomy and ventilation. Adequacy of oxygenation and ventilation are important considerations. Other factors include distance to nearest emergency department, parental preferences and parental ability to recognise and manage sudden deterioration. Episodes of apnoeic spells would support surgical intervention. For patients, in whom the compression by aberrant innominate artery decreases the tracheal lumen significantly, an arteriopexy may be advocated.