Airway Management for Ventilation Instability After Tracheostomy in Pediatric Patients With Tracheobronchomalacia

Pediatric patients with tracheobronchomalacia may require tracheostomy for long-term mechanical ventilation. Ventilator instability can persist despite a stable tracheostomy tube and is characterized by desaturations, rising pressure requirements, or the need for cardiopulmonary resuscitation. There is a paucity of data on the management of ventilatory instability in tracheostomy and ventilator-dependent pediatric patients.

To evaluate inpatient airway outcomes after tracheobronchoscopy in pediatric patients with tracheostomy and ventilatory dependence.

Retrospective chart review of tracheostomy- and ventilator-dependent pediatric patients who underwent inpatient bedside tracheobronchoscopy at an academic tertiary referral center from 2017 to 2023. Primary endpoints are positive end expiratory pressure (PEEP) adjustment, tracheostomy tube change, otolaryngologic operative intervention, or medication addition.

There were 132 patients (median 6 months, IQR [4.7-8.4]) who underwent 204 tracheobronchoscopies for ventilatory instability or about 1.5 ± 0.6 bronchoscopies per admission. Of 157 endoscopies that met criteria, 56 (36%) had PEEP adjustment (1.7 ± 2.2 cmH₂O), 57 (36%) had tracheostomy tube size change, 4 (3%) required operations, and 19 (12%) received a medication course. Seventy-three (46%) patients had an improved hospital status. PEEP adjustment (6.9 vs. 4.8 cmH₂O, p = 0.04) and medical management (9.6 vs. 6.4 cmH₂O, p = 0.03) were associated with 24 h PIP range improvement but not FiO₂ improvement. Trach change was not associated with improvement. Patients who underwent tracheostomy change were more likely to receive subsequent bronchoscopy (21% vs. 8%, p = 0.02) and less likely to have improved hospital status (36% vs. 52%, p = 0.04).

Ventilation instability in tracheostomy-dependent children has variable causes. Airway management can be first directed by flexible tracheobronchoscopy for intervention.