Tracheomalacia is a condition characterized by weakened tracheal walls, due to which the trachea collapses during expiration, resulting in dyspnea. Patients with severe motor and intellectual disabilities have many causes of tracheomalacia. They need to lie in bed for long periods; therefore, their chest wall becomes deformed and the thoracic vertebrae and brachiocephalic artery compress the trachea. In addition, they frequently develop aspiration pneumonia.
The patient was a 37-year-old man with spastic cerebral palsy who underwent surgical implantation of an intrathecal baclofen pump. He developed aspiration pneumonia after the intrathecal baclofen pump replacement and could not be weaned off the ventilator. We performed laryngotracheal separation (LTS) to prevent aspiration. One week after the LTS, the patient was taken off the ventilator, but he developed lower airway obstruction the same night. Tracheomalacia was confirmed by bronchoscopy. We treated the patient with antibiotics and positive pressure ventilation. No operation to expand the trachea was performed.
The patient had many causes of tracheomalacia, but had never developed lower airway obstruction. The findings suggests that the tracheomalacia was aggravated by the tracheal stoma. During spontaneous breathing, a positive end-expiratory pressure of approximately 3 to 5 cm H2O is maintained during expiration to prevent alveolar collapse. When a tracheal stoma is present, that negative intrathoracic pressure is lost because the glottis cannot close properly. In tracheomalacia, the trachea may be obstructed by the loss of this small intrathoracic positive pressure, due to the loss of rigidity of the trachea. Patients who are asymptomatic but are at a high risk of tracheomalacia should be carefully monitored for asphyxiation after tracheostomy or LTS.
