In a 2‑year‑old child with recurrent pneumonia and severe expiratory tracheal stenosis on flexible bronchoscopy, which is the most appropriate immediate management: incentive spirometry, high‑flow nasal oxygen, or non‑invasive mechanical ventilation?

Management of Severe Expiratory Tracheal Stenosis in a 2-Year-Old with Recurrent Pneumonia

None of the three options listed (incentive spirometry, high-flow nasal oxygen, or non-invasive mechanical ventilation) represent appropriate definitive management for severe tracheal stenosis in a 2-year-old child. The child requires surgical or interventional bronchoscopic treatment, with continuous positive airway pressure (CPAP) serving as the most appropriate temporizing respiratory support if immediate intervention is not feasible.

Why the Listed Options Are Inadequate

• Incentive spirometry is completely inappropriate for a 2-year-old child, as this technique requires voluntary cooperation and understanding that children cannot reliably perform until at least 3-5 years of age 1
• High-flow nasal oxygen addresses hypoxemia but does not provide the positive distending pressure needed to maintain airway patency in severe tracheal stenosis 1
• Non-invasive mechanical ventilation may worsen dynamic airway collapse during expiration in severe tracheomalacia or stenosis, as the positive pressure during inspiration followed by passive expiration can exacerbate collapse 1

Appropriate Management Algorithm

Immediate Assessment and Stabilization

• Evaluate for signs of severe respiratory distress including grunting, nasal flaring, head nodding, tracheal tugging, intercostal retractions, and severe tachypnea (≥60 breaths/minute in this age group), as these indicate impending respiratory failure 1, 2
• Monitor oxygen saturation continuously, as SpO₂ <90% indicates severe hypoxemia requiring immediate intervention 1, 2
• Assess for complications of recurrent pneumonia including atelectasis, hyperinflation, and aspiration, which commonly accompany severe tracheal stenosis 3

Definitive Diagnostic Evaluation

• Rigid bronchoscopy under anesthesia with spontaneous breathing is superior to flexible bronchoscopy for defining the exact location, length, and severity of tracheal stenosis, and allows for therapeutic intervention during the same procedure 1
• Dynamic airway assessment during both inspiration and expiration is critical, as the stenosis manifests primarily during expiration in this case 1
• Evaluate for associated conditions including gastroesophageal reflux (present in many cases), vocal cord dysfunction, and other congenital airway anomalies that contribute to recurrent pneumonia 1, 4

Respiratory Support Strategy

If immediate surgical intervention is not possible, continuous positive airway pressure (CPAP) at 10 cm H₂O is the treatment of choice for severe tracheal stenosis or tracheomalacia in young children 3. This approach:

• Provides continuous positive distending pressure throughout the respiratory cycle, maintaining airway patency during the critical expiratory phase when collapse occurs 3
• Can be delivered via tracheostomy in severe cases, allowing for long-term management (13-25 months in published series) with gradual weaning as the child grows and the airway matures 3
• Has demonstrated successful outcomes in infants with severe tracheobronchomalacia who failed extubation and had recurrent pneumonia 3

Definitive Treatment Options

• Endoscopic airway stenting should be considered for severe stenosis refractory to other treatments, with technical success rates of 95% and clinical improvement in 85% of pediatric patients, though complications occur in 27% 5
• Surgical options including tracheopexy, resection, or tracheobronchoplasty may be necessary depending on the exact anatomy and severity 3
• Balloon dilation can be performed during rigid bronchoscopy for certain types of stenosis 1

Critical Management Pitfalls to Avoid

• Do not delay bronchoscopic evaluation in children with recurrent pneumonia and suspected airway abnormalities, as flexible bronchoscopy identifies specific diagnoses in 33% of cases, with malacia disorders and stenosis being among the most common findings 4
• Do not assume the stenosis is the only problem: evaluate thoroughly for aspiration, gastroesophageal reflux (requiring fundoplication in some cases), and immunodeficiency, as these commonly coexist 3, 6
• Do not use flexible bronchoscopy alone for definitive assessment, as it is inferior to rigid bronchoscopy for evaluating the subglottis and for therapeutic interventions 1
• Recognize that recurrent pneumonia in the same location (particularly right upper lobe) may indicate anatomic abnormalities requiring surgical resection if bronchiectasis develops 7

Multidisciplinary Approach

Management should involve a multidisciplinary aerodigestive team including pediatric pulmonology, otolaryngology, and thoracic surgery, as this approach reduces adverse outcomes during airway evaluations and subsequent management 1.