What is tracheal buckling in patients with a history of tracheostomies or respiratory issues?

Tracheal Buckling: Definition and Clinical Context

Tracheal buckling refers to the abnormal folding, kinking, or collapse of the tracheal wall, typically occurring when the trachea loses its normal structural rigidity and bends upon itself, creating airway obstruction. This phenomenon is distinct from tracheomalacia (softening of tracheal cartilage) but often occurs in conjunction with it.

Pathophysiology and Mechanism

Tracheal buckling develops when the tracheal cartilaginous rings lose their structural integrity, allowing the trachea to fold or collapse during respiration. This can occur through several mechanisms:

• Cartilage weakening from prolonged pressure, ischemia, or inflammation leads to loss of the trachea's ability to maintain its tubular shape 1
• Excessive tracheal length relative to the thoracic cavity can cause redundancy and folding of the airway 1
• Dynamic collapse during forced expiration or coughing when intrathoracic pressure exceeds the structural support capacity of weakened tracheal walls 1

Relationship to Tracheostomy and Intubation

In patients with tracheostomy history, tracheal buckling is a recognized complication that develops through specific injury patterns:

• Prolonged cuff inflation causes tracheal ischemia and subsequent cartilage necrosis, particularly when cuffs are overinflated to prevent air leaks—a practice that became more common during COVID-19 management 1
• Tracheal dilation from chronic pressure creates a widened, floppy segment that lacks structural support and is prone to buckling 1, 2
• Tracheomalacia frequently coexists with buckling, as both result from cartilage damage; this is particularly common in patients with esophageal atresia-tracheoesophageal fistula who undergo tracheostomy 1

Clinical Presentation and Recognition

Patients with tracheal buckling typically present with respiratory symptoms that may be mistaken for other complications:

• Dyspnea on exertion is the hallmark symptom, as the dynamic nature of buckling worsens with increased respiratory effort 1
• Stridor or wheeze may occur when the buckled segment creates turbulent airflow 1
• Difficulty clearing secretions results from the kinked airway preventing effective cough 1
• Recurrent respiratory infections develop from impaired mucociliary clearance in the buckled segment 1

Critical Red Flags During Active Tracheostomy Management

If buckling occurs acutely in a patient with a tracheostomy tube in place, specific warning signs emerge:

• Increasing airway pressure on mechanical ventilation without other explanation 1
• Reducing tidal volumes despite constant ventilator settings 1
• Inability to pass a suction catheter beyond a certain point in the trachea 1
• Surgical emphysema developing from air forced into tissue planes around a buckled, partially obstructed airway 1, 3

Diagnostic Approach

Endoscopic airway assessment is the preferred and definitive modality to diagnose tracheal buckling, as it allows direct visualization of the dynamic collapse during respiration 1.

Additional diagnostic considerations include:

• Bronchoscopy should be performed with the patient breathing spontaneously when possible, as positive pressure ventilation may artificially splint the airway and mask the buckling 1
• CT imaging can identify structural abnormalities but may miss dynamic buckling that only occurs during certain phases of respiration; the role of CT in evaluating this condition requires further study 1
• Contrast studies are less useful for buckling specifically but may identify associated vascular compression or tracheoesophageal fistula 1

Management Principles

Treatment depends on the severity and clinical impact of the buckling:

• Conservative management with humidification, aggressive pulmonary toilet, and treatment of underlying inflammation may suffice for mild cases 1
• Positive pressure support (CPAP or BiPAP) can provide pneumatic stenting to keep the airway open in moderate cases 1
• Surgical intervention with tracheal resection and anastomosis is definitive treatment for severe, symptomatic buckling causing significant obstruction 4, 5

Special Considerations for Decannulation

In patients with tracheostomy and suspected buckling, decannulation planning requires careful assessment:

• The tracheostomy tube itself may be providing structural support to a buckled segment, and removal could precipitate acute obstruction 6
• Endoscopic evaluation before decannulation is essential to identify buckling that may become symptomatic once the tube is removed 1, 6
• Gradual downsizing and capping trials should be performed with close monitoring for respiratory distress that might indicate underlying buckling 6

Prevention Strategies

Meticulous cuff pressure management is the single most important preventive measure, as excessive cuff inflation is the primary modifiable risk factor for tracheal injury leading to buckling 1.

Additional preventive measures include:

• Cuff pressures should be maintained at 20-30 cm H2O and checked regularly, avoiding the temptation to overinflate to prevent air leaks 1
• Early tracheostomy tube downsizing once clinically appropriate reduces chronic pressure on tracheal walls 6
• Proper tube selection with appropriate diameter, length, and curvature minimizes focal pressure points 6

Long-term Follow-up

All patients with prolonged intubation or tracheostomy require surveillance for tracheal stenosis and structural abnormalities including buckling at ICU follow-up 1.

This is particularly important because:

• Symptoms may develop months to years after decannulation as the trachea remodels and scar tissue matures 1, 5
• The incidence of symptomatic tracheal complications is approximately 1% of tracheostomy patients, though structural changes may be present in up to 8.8% 5, 7
• Mortality from severe tracheal stenosis and related complications approaches 7.9%, making early detection critical 5