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

Objective: To investigate the impact of positive end-expiratory pressure (PEEP) titrations or tracheostomy size change (trach change) on ventilation stability in infants with tracheobronchomalacia.

Study design: A retrospective chart review.

Setting: Tertiary care children's hospital from 2015 to 2023.

Methods: A retrospective chart review on ventilator and tracheostomy-dependent patients <1 year of age. Demographics, bronchoscopic findings, and ventilator outcomes within 14 days were recorded. Analysis was performed with chi-square, Fisher's exact, binomial regression analysis, and two-tailed t tests.

Results: Of 71 patients (66% male, median 6.1 months old [interquartile range, IQR, 4.6-7.3]) who underwent 74 initial bronchoscopies, the PEEP titration cohort (n = 37) experienced an improvement (narrower) in 24-hour mean ventilatory ranges (peak inspiratory pressure [PIP] 5.6 pre vs 2.9 post, P = .01; fraction of inspired oxygen [FiO₂] range 5% vs 3%, P = .04), whereas the trach change cohort did not (PEEP 5.9 vs 5.6, P = .8; FiO₂ 10% vs 5%, P = .07). In patients with airway malacia, the PEEP titration cohort had improved PIP ranges postintervention (5.5 vs 3.0, P = .02), whereas the trach change cohort did not (4.4 vs 6.6, P = .13). In patients without airway malacia, trach change correlated with improved PIP (8.4 vs 3.8, P = .04). Repeat bronchoscopy after initial intervention was significantly more common after trach change compared to PEEP titration (22% vs 3%, P = .01).

Conclusion: PEEP titration was associated with improved PIP and FiO₂ ventilatory outcomes with a lower rate of repeat bronchoscopy compared to trach change, suggesting trach change alone may have little impact with greater subsequent interventional needs compared to PEEP titration.