Postoperative Ventilatory Management with Noninvasive Positive-pressure Ventilation in a Child with a Severe Tracheomalacia

To the Editor:—

Children with tracheomalacia are at high risk of postoperative respiratory distress for non–upper airway surgery and of prolonged tracheal intubation. Noninvasive positive-pressure ventilation (NPPV) via  facial mask is a method of providing mechanical ventilatory support without tracheal intubation. 1We report the case of a 6-month-old, 7.4-kg male patient with severe tracheomalacia in whom respiratory failure developed after surgery for gastroesophageal reflux. The child had a full-term gestation with a type III esophageal atresia that was repaired on the day of birth. He had tracheomalacia and a tracheolaryngeal cleft (type 2-b) without respiratory insufficiency. For the current procedure, the trachea was intubated with a 3.5-mm ID nasotracheal tube. The procedure was uneventful, and he underwent extubation after completion. He developed signs 1 h later of upper airway obstruction with severe bradycardia, necessitating manual ventilation and atropine. He was administered supplemental oxygen, intravenous steroids, and aerosolized racemic epinephrine, without improvement. To avoid tracheal reintubation, NPPV via  facial mask was instituted in the timed spontaneous mode with use of a ventilatory support system (BiPAP; Respironics, Murrysville, PA). Initially, inspiratory positive airway pressure was set at 12 cm H²O, and expiratory positive airway pressure was set at 5 cm H²O, with a mechanical respiratory rate of 25 breaths/min. Eleven hours later, Inspiratory positive airway pressure was increased to 16 cm H²O, expiratory positive airway pressure was increased to 10 cm H²O, and administration of 1 l/min–flow oxygen with a fraction of inspired oxygen of 0.3 was started via  the mask. Arterial blood gas measurements showed a pH of 7.33, an arterial carbon dioxide tension of 47.2 mmHg, and an arterial oxygen tension of 63.7 mmHg. The ventilator settings were not changed for 26 h, when respiratory status began to improve. Oxygen supplementation was discontinued. The levels of support were decreased gradually, and NPPV was discontinued on postoperative day 2, with no recurrence of upper airway obstruction. A nasogastric tube placed for surgery allowed reduction of gastric distension. The antireflux procedure probably minimized the risk of aspiration. Analgesia was achieved with use of nalbuphine. Initially, the child required sedation with intravenous diazepam for comfort. Feeding was started on postoperative day 5. The child was discharged to his home on postoperative day 10.

Postoperative respiratory management of children with tracheomalacia can be a major challenge. NPPV has been described widely in pediatric patients with acute respiratory failure. 2However, there are few reports about the use of NPPV in the postoperative period in children. 3Our report indicates that NPPV may be attempted before reintubation in infants requiring airway support, with careful attention given to the risks of aspiration and respiratory muscle fatigue.