From the Guidelines
Management of TOS 1-4 retractions in pediatric tracheostomy emergencies involves an immediate attempt at re-insertion of the tracheostomy tube if it has become completely displaced from the neck, unless the child was being considered for a trial of decannulation, as recommended by Doherty et al. 1. When managing TOS 1-4 retractions, it is crucial to prioritize airway patency and stability. The first step is to assess the tracheostomy tube for patency and consider an emergency tracheostomy tube change if the tube is blocked or partially displaced, as this can be considered a foreign body in the trachea that must be removed 1. Some key considerations in this process include:
- Using a tracheostomy tube of the same size as the one removed for the first emergency tube change, without an exchange guide such as a bougie, wire, or suction catheter 1
- Utilizing a dedicated obturator to ease insertion, reduce trauma, and protect the stoma 1
- Assessing patency of the replacement tube through clinical evaluation and waveform capnography if available, and considering gentle hand ventilation via the tracheostomy tube if the child has reduced or absent respiratory effort 1
- If the first attempt at replacement is unsuccessful, performing a second emergency tube change with a tube one half-size smaller, followed by assessing for airway patency 1
- Considering a third attempt using a soft suction catheter to guide placement, similar to a Seldinger technique, if the second attempt is unsuccessful 1
- Recognizing the potential difficulties in replacing the tube due to structural airway anomalies, a distressed child, or spasm of the surrounding tissues, and being prepared to address these challenges 1.
From the Research
Management of TOS 1-4 Retractions
- The management of thoracic outlet syndrome (TOS) depends on the type of TOS, with treatment algorithms varying for neurogenic, venous, and arterial TOS 2.
- For neurogenic TOS, initial treatment is often conservative, with data limited on the effectiveness of different treatment methods or combinations 3.
- Surgery is considered for refractory cases of neurogenic TOS, while anticoagulation and surgical decompression are the treatment of choice for vascular versions of TOS 3.
- A multidisciplinary approach is necessary for proper treatment of TOS, regardless of the type encountered 2.
- The use of transaxillary first rib resection and supraclavicular neuroplasty of the brachial plexus has been studied, with low-quality evidence suggesting that transaxillary first rib resection may decrease pain more than supraclavicular neuroplasty 4.
- Botulinum toxin injections into the scalene muscles have also been investigated, with moderate evidence suggesting that they yield no significant improvements over placebo injections of saline 4.
- Conservative treatment programs, such as those aiming to restore normal function to the upper thoracic aperture, have been shown to provide relief to most patients with symptoms of TOS, with high patient satisfaction and return to work rates 5.
Treatment Options
- Surgical intervention, including first rib resection and anterior scalenectomy, may be necessary for some patients with TOS, particularly those with arterial or venous TOS 2.
- Thrombolysis may be used to restore blood flow in cases of arterial or venous thrombosis 2.
- Conservative treatment methods, such as physical therapy and home exercises, may be effective in managing symptoms of neurogenic TOS 3, 5.
- The use of botulinum toxin injections and other interventions, such as oxygen therapy, may also be considered, although evidence for their effectiveness is limited 6, 4.
Diagnostic Considerations
- Diagnosis of TOS is often clinical, with the upper limb tension test (ULTT) being a useful screening tool 3.
- Additional diagnostic testing, such as ultrasound, electromyography (EMG), or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA), may be necessary to distinguish between vascular and neurological etiologies of symptoms 3.
- A comprehensive diagnostic approach is necessary to ensure accurate diagnosis and effective treatment of TOS 2, 3.