Endotracheal stent placement for pediatric blunt traumatic tracheal perforation

Bronchoscopy showing tracheal perforation and deployed stent in a pediatric patient.

Central Message.

Endotracheal stent placement can offer a safe and effective alternative to prolonged intubation or surgery for blunt traumatic tracheal injuries in appropriately selected pediatric patients.

Traumatic tracheobronchial injuries are rare and potentially life-threatening.¹ Although traditional management involves neck exploration with or without partial sternotomy, or right thoracotomy, endoscopic therapies have expanded the interventions available.^2,3 We present a case of pediatric traumatic tracheal perforation successfully managed with endotracheal stent placement that avoided prolonged intubation or open surgical repair.

Case Report

A 12-year-old boy with no significant medical history was transferred as a level-1 trauma patient after a bicycle accident with a handlebar injury to the neck. Physical examination revealed a circular abrasion to the anterior neck, subcutaneous emphysema, and no respiratory distress. Computed tomography scanning of the neck and chest demonstrated a posterior tracheal perforation, pneumomediastinum, and cervical emphysema without vascular injury (Figure 1, A and B). The computed tomography scan was shared before transfer, enabling a multidisciplinary team, including pediatric surgery, adult thoracic surgery, and interventional pulmonology to prepare for the patient's arrival. Despite worsening subcutaneous emphysema, the patient remained hemodynamically stable and breathing spontaneously, so intubation was deferred for expedited transfer and to avoid further injury to the airway. Due to the injury location and the patient's stable condition, endotracheal stent placement was chosen to minimize the morbidity associated with open surgical repair in a pediatric patient. The absence of severe respiratory distress further supported the decision to pursue endoscopic management. In the event of stent failure, we planned to perform primary repair via a transcervical approach using a low cervical collar incision with midline extension and manubrial spreading if additional exposure became necessary.

Figure 1.

A and B, Computed chest tomography demonstrates right posterior membranous tracheal perforation with pneumomediastinum (yellow arrows). C, Right posterior tracheal laceration with visualization into the mediastinum with respirations. D, Fully covered nitinol tracheobronchial stent positioned with appropriate coverage of tracheal defect.

The patient was taken to the operating room for emergency treatment, where an adult diagnostic bronchoscope (Olympus BF-H190) was introduced through a laryngeal mask airway (Video 1) revealing a 3.0-cm longitudinal full-thickness, level 3A membranous wall tear on the right side of the trachea, at the junction of membranous wall and cartilaginous ring, with direct visualization into the mediastinum during respiration (Figure 1, C). The defect ends were 2.5 cm distal to the cricoid and 5.5 cm proximal to the carina. A Pulmonary Jagwire (Boston Scientific) was placed down the right main bronchus, and an AERO 16 × 40 mm self-expanding fully covered nitinol tracheobronchial stent (Merit Endotek) was deployed over the wire under fluoroscopy, covering approximately 1 cm proximal and distal to the injury (Video 1 and Figure 1, D). Esophagoscopy before stent placement revealed no associated esophageal injury.

The patient was monitored in the pediatric intensive care unit for 48 hours postoperatively for potential stent migration. Chest radiography on postoperative days 1 and 2 confirmed appropriate stent position. Pulmonary hygiene, including scheduled nebulized 3% saline and albuterol, was administered to promote mucous clearance, whereas antimicrobial therapy was administered for mediastinal prophylaxis until stent removal. Bronchoscopic examination on postinjury day 8 revealed a moderate accumulation of secretions within the stent, necessitating more frequent surveillance to prevent stent occlusion and airway compromise (Figure 2, A). After stent removal, the laceration was healing with granulation tissue, but a residual defect persisted that required stent replacement. The patient was then discharged with follow-up (Figure 2, B and C). By day 18 postinjury, bronchoscopy revealed robust granulation tissue covering the defect, and due to adequate healing by secondary intention, the stent was not replaced. Surveillance bronchoscopy, 2 months postinjury, revealed a well-healed tracheal wall without stenosis or malacia (Figure 2, D).

Figure 2.

A, Bronchoscopic examination postinjury day 8, accumulation of secretions within stent lumen. B, Tracheal defect still present, laceration healing with surrounding granulation tissue. C, replacement of tracheal stent. D, Bronchoscopic surveillance 2 months postinjury demonstrates a well-healed tracheal wall without evidence of tracheal stenosis or malacia.

This single-patient case report was exempt from Pennsylvania State University Institutional Review Board review. The patient's legal guardian provided informed written consent for publication of the study data.

Discussion

This report highlights a pediatric trauma involving blunt tracheal perforation managed with a tracheal stent to avoid intubation or open surgical repair. Early diagnosis and management of tracheobronchial injuries is critical. Cardillo and colleagues⁴ proposed a classification for postintubation tracheobronchial lacerations to guide treatment strategies, but no consensus guidelines exist for traumatic injuries. Nonoperative strategies and endoscopic stenting are increasingly utilized based on clinical condition and extent of airway injury.²

Tracheal stent placement for injury management is mostly reported in adults with iatrogenic postintubation injuries.⁵,^E1,^E2 Serio and colleagues³ first described pediatric cases treated with temporary stents, but these involved patients who required endotracheal intubation or tracheostomy before endoscopic evaluation and stent placement due to respiratory failure. To our knowledge, no pediatric cases of blunt traumatic tracheal injury have successfully utilized endotracheal stenting without prior intubation or tracheostomy. In this case, securing the airway in the trauma bay was deferred to avoid worsening the tracheal injury, proceeding directly to definitive endoscopic management.

Conservative management may include observation, tracheostomy, and endotracheal intubation distal to the injury for clinically stable patients with spontaneous breathing, minimal ventilatory requirements, level-1 or -2 injuries, and defects <2 cm, with stable subcutaneous emphysema or pneumomediastinum.^2,E3, E4, E5 Despite the patient's clinical stability, the defect exceeded 2 cm and was accompanied by worsening subcutaneous emphysema, precluding conservative management as a viable treatment strategy.

Surgical repair is generally indicated for lacerations >4 cm, a depth of laceration corresponding to 3A or 3B disruption, or in patients who are clinically deteriorating.^2,E6, E7, E8, E9 The application of adult bronchoscopic techniques to pediatric diseases has led to the use of tracheal stents to manage injuries that historically required surgery.^5,E10,^E11 This patient's full-thickness, level 3A injury and worsening subcutaneous emphysema met traditional criteria for open surgical repair, yet a multidisciplinary approach allowed for a less-invasive intervention.

Temporary tracheal stents are effective by spanning the entire defect, inducing an inflammatory response, and promoting tissue granulation, which leads to defect closure.² However, potential risks include airway obstruction from mucus accumulation or stent migration, and the need for frequent bronchoscopy. In the acute setting, signs of stent failure include stent migration, respiratory distress, and inadequate granulation and defect closure. Successful treatment is indicated by appropriate position on chest radiography and appropriate healing on bronchoscopic examination.

Early multidisciplinary coordination enabled a tailored treatment plan leading to an excellent outcome. This approach may not be feasible at centers with limited experience in advanced bronchoscopic techniques. Multidisciplinary evaluation and appropriate patient selection are essential to identify patients that will benefit from endotracheal stent placement.

Conflict of Interest Statement

The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Supplementary Data

Video 1

Bronchoscopic examination of injury and endotracheal stent placement. Video available at: https://www.jtcvs.org/article/S2666-2507(24)00516-9/fulltext.