Tracheostomy Tube Change vs PEEP Titration on Tracheostomy-Dependent Infants With Airway Malacia and Ventilator Instability

Introduction: Tracheobronchomalacia is a common concurrent airway pathology found in infants who require tracheostomy for long-term ventilation often associated with acute desaturations during agitation/Valsalva maneuvers (ventilator instability). Bronchoscopy with positive end expiratory pressure change (PC) or tracheostomy tube size change (TC) are often employed to mitigate these events, but the effectiveness of these interventions remains understudied.

Methods: A retrospective chart review of flexible bronchoscopies performed from 2015-2023 on ventilator and tracheostomy-dependent patients under 1 years of age in a tertiary care children’s hospital was performed. Demographic data, bronchoscopic findings, ventilator settings, post-bronch interventions (PEEP change, trach change, repeat bronchoscopy), and clinical improvement (downgrade or discharge within 14 days) were recorded. Analysis was performed with chi square, Fisher's exact, and two tailed t-tests.

Results: Of 137 patients (69% male, median 6.1 months old [IQR 4.4-7.3]) who underwent bronchoscopy, 22 (16%) had only tracheomalacia (TM), 33 (24%) had only bronchomalacia (BM), 46 (34%) had tracheobronchomalacia (TBM), and 36 (26%) had no malacia. TC occurred in 14 (64%), 11 (33%), and 15 (33%) of patients with TM, BM, and TBM, respectively. Average trach size change was +24 mm in outer diameter and 17 mm longer. PC occurred in 6 (27%), 15 (45%), and 31 (67%) of patients with TM, BM, & TBM, respectively. Average PEEP change was delta 2.5cm H2O. In patients with any airway malacia, repeat bronchoscopy within 14 days occurred more often after TC than after PC (13% vs 0%, p = 0.01). Fewer patients after TC had clinical status improvement compared to those who received PC (5% vs 25%, p = 0.01).

Conclusions: In tracheostomy-dependent patients with airway malacia and ventilation instability, tracheostomy size change was associated with greater repeat bronchoscopy needs without clinical improvement suggesting these adjustments may have little impact on improving ventilation stability compared to PEEP titration.