Dr. M.M. Zameer
Consultant Pediatric Laparoscopic and Robotic Surgeon
A five month old girl, presented with a congenital heart disease (large PDA with small VSD). She was scheduled for surgery (PDA ligation). In the operation theatre, it was not possible to intubate with an age-appropriate sized tube.
After much difficulty she was intubated with a very small sized tube. She underwent PDA ligation, but ventilation continued to remain ineffective. The child was kept in the OR and we, the pediatric surgical team was called in.
It was clear that the child had a congenital central airway obstruction – possibilities being a laryngeal or tracheal stenosis. An airway assessment was not possible given the child’s precarious airway access and ventilation. A tracheostomy, a standard rescue procedure in this situation, was not possible as tracheal stenosis was a possibility. The child was also too unstable to move to the CT scan suite for imaging.
On reviewing her X-rays, the trachea was thought to be narrow along its entire length – a diagnosis of long segment tracheal stenosis was suspected. In order to stabilize the child for a proper assessment and repair, she was put on a cardiopulmonary bypass via a sternotomy. Once she was stabilized on the CPB, the endotracheal tube was removed, and a complete airway assessment was performed. The diagnosis of long segment congenital tracheal stenosis was confirmed. The entire trachea, from the 2nd tracheal ring up to and including the carina was involved. In this condition, the usual incomplete tracheal rings are replaced by complete rings.
An emergency slide tracheoplasty was performed in the same sitting ( by Dr Sanjay Rao and Me). The tracheal repair extended from the 2nd tracheal ring up to the carina- which was also augmented. After the repair, an endoscopy confirmed a good caliber of trachea and carina. An age-appropriate endotracheal tube could now be placed, and the child rapidly weaned off the CPB.
In the ICU she was extubated on the 4th day post op and made a rapid and unremarkable recovery. She was initiated on early oral feeding and discharged home 10 days after her surgery.
Fig 1: Trachea bisected in middle showing complete tracheal rings.
Fig 2 : Final result showing repaired trachea.
Congenital tracheal stenosis is a rare and potentially life-threatening condition. As many of these children also have associated cardiac anomalies, the tracheal stenosis is often missed. It is, not infrequently, discovered at the time of induction of anesthesia when it is not possible to intubate the child.
An increased awareness of this condition and the presence of multi-disciplinary teams within the Narayana Health City, allowed an optimal emergency management of this difficult problem. The anesthetic, cardiac surgical, pediatric surgical and ICU teams worked together to ensure that the child had a successful outcome.
The Pediatric Surgical team at NH Bangalore has expertise in the surgical management of complex airway anomalies such as tracheal and laryngo-tracheal stenosis. We have performed over 100 complex airway reconstructions. We have also performed over 2 dozen tracheal reconstructions (including more than 15 slide tracheoplasties). A multi-disciplinary airway team provides comprehensive and efficient care for children with complex airway anomalies and has, over time, become a major referral center for these types of problems.