Abstract Introduction Tracheobronchomalacia (TBM), characterized by dynamic collapse of the central airways, is a frequently overlooked contributor to respiratory instability in the critically ill. Its clinical presentation can masquerade as refractory hypoxemia, tachypnea, or poor ventilator synchrony, especially in the context of sepsis and metabolic derangements, complicating both diagnosis and management in the intensive care unit. Failure to identify this condition can result in inappropriate management strategies, such as escalating ventilator settings or unnecessary reintubations, which may worsen airway collapse and patient outcomes. Case A 90-year-old woman with atrial fibrillation, diabetes mellitus, and Alzheimer’s disease presented with vomiting, diarrhea, dyspnea, hypotension, and tachycardia. Laboratory evaluation revealed leukocytosis, elevated lactate, acute kidney injury, and hyperglycemia. Urinalysis and culture confirmed multidrug-resistant Escherichia coli. Chest computed tomography demonstrated a right upper-lobe mass and severe tracheobronchial collapse consistent with tracheobronchomalacia (Figure 1). She was admitted to the intensive care unit for sepsis and airway monitoring. Management included fluid resuscitation and broad-spectrum intravenous antibiotics. Given her frailty and airway findings, pulmonology recommended conservative airway management and avoidance of elective intubation. The patient’s hemodynamics and renal function normalized, and she was discharged to a skilled-nursing facility with outpatient pulmonary follow-up. Discussion This case highlights the critical importance of recognizing tracheobronchomalacia in the setting of acute illness, where sepsis physiology may unmask previously compensated airway collapse. Epidemiologic data indicate TBM is underdiagnosed, with bronchoscopy series reporting a prevalence of 1-4.5% among patients evaluated for respiratory symptoms. Diagnostic challenges include nonspecific symptoms and variability in imaging interpretation, underscoring the need for standardized diagnostic criteria and multidisciplinary collaboration. To address these limitations, clinicians must maintain a high index of suspicion in patients with predisposing factors (e.g., obesity, gastroesophageal reflux, prior prolonged intubation, or congenital airway anomalies) who present with unexplained respiratory failure. Recognizing these subtle presentations is particularly crucial in the ICU, where TBM may be unmasked by systemic stressors such as sepsis. Early identification in this case fundamentally altered management, favoring noninvasive oxygenation and cautious fluid strategy over positive-pressure ventilation, given the high risk of extubation failure and prolonged ICU stay in patients with TBM. The novelty of this case lies in this intersection of infectious and structural pathology, highlighting the importance of individualized airway strategies, early recognition, and integrated critical care management to optimize patient outcomes. This abstract is funded by: None
Hassan et al. (Fri,) studied this question.