In a patient with a tracheostomy and severe tracheomalacia (≈90% expiratory airway collapse confirmed by bronchoscopy), which is the most appropriate adjunctive therapy: negative pressure ventilation, non‑invasive positive‑pressure ventilation, or high‑flow nasal cannula?

Management of Severe Tracheomalacia with Tracheostomy

In a patient with tracheostomy and severe tracheomalacia (90% expiratory collapse), non-invasive positive pressure ventilation is the most appropriate adjunctive therapy to provide continuous positive airway pressure that splints the airway open and prevents expiratory collapse. 1

Rationale for Positive Pressure Support

The fundamental pathophysiology of severe tracheomalacia is dynamic airway collapse during expiration, which creates life-threatening airway obstruction. Continuous positive airway pressure (CPAP) or other forms of positive pressure ventilation provide pneumatic stenting of the collapsing airway, maintaining patency throughout the respiratory cycle. 1

• Long-term CPAP through a tracheostomy tube has been successfully used to manage severe tracheobronchomalacia, with treatment durations ranging from 13 to 25 months until the airway matures and the condition resolves. 1
• Initial CPAP pressures of 10 cm H₂O are typically required, with gradual weaning achieved by decreasing both pressure and duration of treatment per day. 1
• This approach serves as a reasonable alternative or adjunct to surgical procedures such as tracheopexy, resection, or tracheobronchoplasty. 1

Why Non-Invasive Ventilation (Option B) is Correct

Non-invasive ventilation encompasses bi-level positive airway pressure and CPAP delivered through interfaces, and when applied via tracheostomy, provides the positive pressure needed to prevent airway collapse. 2

• The tracheostomy provides direct access to deliver positive pressure below the level of collapse, making it highly effective for tracheomalacia management. 1
• Positive pressure ventilation via tracheostomy is the most common method of providing home mechanical ventilation in patients requiring chronic respiratory support. 2

Why Other Options Are Inappropriate

Negative Pressure Ventilation (Option A)

Negative pressure ventilation is contraindicated in tracheomalacia because it worsens expiratory collapse by creating sub-atmospheric pressure around the thorax, which increases the transmural pressure gradient and exacerbates airway collapse. 2, 3

• Negative pressure ventilation works by applying sub-atmospheric pressure to the chest wall surface, which would paradoxically worsen the dynamic collapse characteristic of tracheomalacia. 2
• This modality has no role in managing conditions where airway structural support is compromised. 2

High-Flow Nasal Cannula (Option C)

High-flow nasal cannula is inappropriate because the patient already has a tracheostomy, rendering nasal oxygen delivery ineffective—the gas would simply escape through the tracheostomy stoma rather than reaching the lungs. 2

• High-flow nasal cannula is defined as heated humidified oxygen delivered through nasal prongs, which cannot function when a tracheostomy bypasses the upper airway. 2
• Even if the upper airway were patent, high-flow nasal cannula provides minimal positive pressure compared to CPAP and would be insufficient to splint open a 90% collapse. 2

Clinical Management Algorithm

For severe tracheomalacia with tracheostomy:

1. Initiate CPAP or positive pressure ventilation via the tracheostomy tube at 8-10 cm H₂O. 1
2. Monitor for clinical improvement in respiratory distress, cyanotic episodes, and recurrent infections. 3, 1
3. Maintain positive pressure support continuously until the airway matures, typically requiring 13-25 months of treatment. 1
4. Wean gradually by decreasing both pressure levels and hours of daily use as tolerated. 1
5. Consider surgical intervention (aortosternopexy or tracheopexy) if positive pressure support fails or if anatomic correction is feasible. 4, 5, 6

Critical Pitfalls to Avoid

Never use negative pressure ventilation in tracheomalacia, as it will worsen the collapse and can precipitate life-threatening airway obstruction. 2, 3

• Severe tracheomalacia is associated with significant morbidity and mortality that should not be underestimated, including life-threatening cyanotic attacks. 3
• Mild cases may be managed expectantly, but 90% collapse is severe and requires active intervention to stabilize the airway. 3, 4
• Efficient physiotherapy and management of concurrent conditions (such as gastroesophageal reflux) are important adjuncts but do not replace the need for positive pressure support in severe cases. 1, 4