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Initial Assessment and Approach If possible, maintain spontaneous ventilation until the airway injury is isolated Avoid positive pressure ventilation initially as it can worsen injury or cause pneumomediastinum Patient should remain awake during initial management if possible Visualization and Diagnosis Direct visualization of the injury is crucial before any intervention Preferred methods: Flexible fiberoptic bronchoscopy or Rigid bronchoscopy (though may be poorly tolerated in awake patients) Location and size of injury must be identified to guide management Intubation Strategy Awake fiberoptic intubation while maintaining spontaneous breathing is preferred Avoid blind passage of any tubes or catheters Direct laryngoscopy is generally not recommended unless injury is known to be small Endotracheal tube placement depends on injury location: Proximal tracheal injury: Single-lumen tube placed beyond the tear Carinal or distal injury: Consider double-lumen tube or bronchial blocker Sedation options: Midazolam or dexmedetomidine can be used but may worsen airway obstruction Ketamine or inhalational agents are possible alternatives Avoid: Jet ventilation (risks similar to positive pressure ventilation) Laryngeal mask airways (don't secure or isolate the injury) Muscle relaxants (require PPV) Emergency Management: Surgical airway (tracheostomy) should be considered if: Patient cannot maintain spontaneous ventilation Fiberoptic intubation fails Patient becomes unstable