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

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

In a 2-year-old child with severe expiratory tracheal stenosis and recurrent pneumonia, invasive mechanical ventilation (Option D) is the most appropriate initial management to secure the airway and prevent life-threatening respiratory failure. 1

Why the Other Options Are Inadequate

• Incentive spirometry (Option A) is completely inappropriate for children younger than 3–5 years because it requires voluntary cooperation and understanding that toddlers cannot provide. 1

• High-flow nasal oxygen (Option B) can correct hypoxemia but does not supply the positive distending pressure needed to keep a severely stenotic airway open during the critical expiratory phase when collapse occurs. 1

• Non-invasive mechanical ventilation (Option C) may paradoxically worsen dynamic airway collapse during expiration in severe tracheomalacia or tracheal stenosis, making it potentially dangerous in this scenario. 1

Clinical Assessment of Severity

In toddlers with severe tracheal stenosis, watch for these signs of impending respiratory failure that mandate immediate intubation: 1

• Grunting, nasal flaring, head nodding, or tracheal tugging
• Intercostal retractions
• Respiratory rate ≥ 60 breaths/min
• SpO₂ < 90% on pulse oximetry

Rationale for Invasive Mechanical Ventilation

The endotracheal tube itself acts as an internal stent, bypassing the stenotic segment and maintaining airway patency throughout both inspiration and expiration. 2, 3 This is critical because:

• Severe expiratory tracheal stenosis causes dynamic collapse during the expiratory phase, leading to air trapping, recurrent pneumonia, and potential life-threatening episodes. 2, 4

• The recurrent pneumonia in this child likely results from impaired secretion clearance due to the stenotic airway, creating a vicious cycle of infection and inflammation. 2, 5

• Once the airway is secured with intubation, the child can be stabilized for definitive diagnostic evaluation and treatment planning. 1

Subsequent Management After Stabilization

After securing the airway with invasive mechanical ventilation:

1. Perform rigid bronchoscopy under anesthesia with spontaneous breathing to provide superior definition of the stenosis location, length, and severity compared to flexible bronchoscopy. 1

2. Assess the airway dynamically during both inspiration and expiration to fully characterize the stenotic segment. 1

3. Consider balloon dilation during rigid bronchoscopy for selected types of tracheal stenosis as a potential therapeutic intervention. 1, 6

4. Evaluate for associated conditions including gastroesophageal reflux, vocal cord dysfunction, and other congenital airway anomalies that commonly coexist with severe tracheal stenosis. 1

5. Transition to CPAP via tracheostomy if prolonged airway support is needed, as this provides continuous positive pressure to maintain airway patency and can be weaned gradually over months as the child grows and the stenosis improves. 3

Multidisciplinary Approach

Management by a dedicated aerodigestive team (pediatric pulmonology, otolaryngology, and thoracic surgery) reduces adverse outcomes during airway evaluation and subsequent treatment. 1 Surgical options may ultimately include aortopexy, posterior tracheopexy, tracheal resection, internal stents, or external airway splinting depending on the specific anatomy and severity. 4

Common Pitfall to Avoid

Do not delay intubation while attempting less invasive respiratory support in a child with severe tracheal stenosis and signs of respiratory distress. The narrow pediatric airway and dynamic nature of expiratory collapse make this a time-sensitive emergency where securing the airway takes precedence over diagnostic procedures. 2, 1