Managing Mechanical Ventilation After Tracheobronchoplasty for Tracheobronchomalacia

Tracheobronchomalacia (TBM) is a structural airway disease characterized by weakness of the supporting anterior airway cartilage. Tracheobronchoplasty is considered the definitive surgical treatment for TBM. Up to 17% of these patients can develop respiratory failure in the acute postoperative period with subsequent difficulty in weaning from the ventilator, mostly due to increased airway pressures and airway resistance. However, no current guidelines exist to address the challenges faced in this patient population as it relates to ventilator management. In this iteration of How I Do It, we use a case-based discussion to review the current relevant literature on TBM and tracheobronchoplasty, and continue with a description of our strategies on mechanical ventilation management in the acute postoperative period and in weaning these patients from the ventilator. Specifically, we review the role of mitigating intrinsically high positive end-expiratory pressure, the use of adaptive support ventilation, and the incorporation of heliox into the management plan. Due to the lack of evidence on the issue, these suggested strategies are based on a single-center experience, and more research is needed to develop formal evidence-based strategies.