Tracheobronchomalacia causing end expiratory grunt post-intubation

Tracheobronchomalacia is a rare, often asymptomatic, progressive disease characterised by a complete or near-complete collapse of the airway during expiration. Only a few cases have been reported as being diagnosed intra-operatively. Here, we report a case of tracheobronchomalacia diagnosed under general anaesthesia in a 52-year-old man undergoing elective excision of basal and squamous cell carcinomas of the scalp, face and arm. A persistent, loud, end expiratory grunt was noted immediately after inflation of the tracheal tube cuff. Oxygenation, ventilation and capnography remained within normal ranges. Flexible bronchoscopy revealed a patent tracheal tube with complete distal collapse of the trachea on expiration to the level of the carina. Increased positive end expiratory pressure was applied and the tracheal tube advanced to splint the trachea open. The grunting sound resolved and surgery proceeded uneventfully. Postoperatively, computerised tomography imaging confirmed the diagnosis. An audible end expiratory grunt immediately post-intubation is unusual and warrants further investigation. Flexible bronchoscopy can be utilised to visualise the dynamic airway collapse that occurs in tracheobronchomalacia.