B46-02 Managing Severe Tracheomegaly in a Ventilator-dependent Patient a Case of Cuff Induced Malacia

An 81-year-old male with a history of undefined progressive muscle weakness, mild OSA, chronic tracheostomy (Shiley #7 distal XLT), and ventilator dependence presented with fever and concern for sepsis. Interventional Pulmonology was consulted for a significant air leak. Chest CT revealed marked tracheomegaly, and bronchoscopy demonstrated severe tracheomalacia. The patient’s ventilator had been alarming for air leaks at home. His wife had been inflating his cuff over the last few months in an attempt to resolve the problem. Introduction: The normal tracheal diameter in an adult male is 16-19 mm. Tracheomegaly is defined as a trachea with a diameter greater than 25 mm. Tracheomalacia is the weakening of the anterior cartilage or longitudinal muscle fibers of the posterior tracheal wall. Typically, 7-10 mL of air is needed to inflate the balloon of a standard Shiley tracheostomy tube, though more air can be added without immediate rupture. Discussion: This patient experienced chronic dilation of the trachea related to repeated overinflation of the cuff. His trachea measured 51 mm in diameter on CT—approximately 1.5 times the normal size. Chronic mechanical ventilation led to continuous cuff inflation, weakening the cartilaginous structures and contributing to tracheal dilation. The resulting enlargement caused persistent air leaks and inconsistent tidal volumes as air escaped around the fully inflated cuff. The solution is to select a tracheostomy tube that allows the cuff to sit distal to the area of malacia. In this case, a hyperflexible adjustable Bivona tracheostomy was used during hospitalization. Conclusion: We present a case of an 81-year-old male with undiagnosed progressive muscle weakness requiring tracheostomy placement and continuous mechanical ventilation. Prolonged cuff inflation led to tracheal dilation and iatrogenic tracheomalacia. It is crucial to educate families and caregivers of tracheostomy-dependent patients on the risks and prevention of cuff overinflation. This abstract is funded by: None