title: Successful conservative management of a rare complication of tracheostomy; extensive posterior tracheal false pouch.
abstract: BACKGROUND
  With the advent of improved neonatal and pediatric intensive care management, tracheostomy is increasingly performed in children requiring prolonged ventilation. Even though tracheostomy is generally a safe procedure, there remains mortality and morbidity associated with it.
  
  
  OBJECTIVE
  We report a rare complication of a tracheostomy tube resulting in extensive erosion and posterior tracheal false pouch secondary to a large tracheostomy tube and high positive end expiratory pressure in a 12-month-old infant. This was managed successfully with conservative treatment.
  
  
  RESULTS
  A former 34-week premature infant was transferred to our pediatrics intensive care unit (PICU) with recurrent episodes of cardiopulmonary arrests due to suspected severe tracheobronchomalacia. The patient has bronchopulomonary dysplasia, severe restrictive lung disease and thoracic insufficiency from skeletal dysplasia requiring tracheostomy tube (TT) at two-month-old and mechanical ventilation. The 3.5 NEO TT was gradually upsized to a 5. The PEEP setting at transfer was 18cmH2O. The direct laryngoscopy and bronchoscopy showed moderate tracheomalacia at the innominate artery with a false pouch in the posterior tracheal wall that was 1.1cm below the tracheostomy stoma. A multi-disciplinary discussion including otolaryngology, PICU, Pulmonary Medicine, and Pediatric Surgery decided on conservative management. The false pouch healed and she was transferred back to referring PICU after a 46-day.
  
  
  CONCLUSIONS
  Tracheal wall erosion resulting in a pouch formation is a rare complication, but it should be considered in patients with long term tracheostomy with difficulty ventilation and oxygenation with positional change. DLB is a useful tool in its diagnosis and conservative management can be successful.
authors.affiliation: University of Michigan Health System, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Ann Arbor, MI, United States. Electronic address: drjennha@yahoo.com.au.
authors.forename: Jennifer F
authors.initials: JF
authors.lastname: Ha
authors.affiliation: University of Michigan Health System, Division of Critical Care Medicine, Department of Paediatrics and Communicable Diseases, Ann Arbor, MI, United States.
authors.forename: Waseem
authors.initials: W
authors.lastname: Ostwani
authors.affiliation: University of Michigan Health System, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Ann Arbor, MI, United States.
authors.forename: Glenn
authors.initials: G
authors.lastname: Green
mesh_terms: D016122:Brachiocephalic Trunk; D001997:Bronchopulmonary Dysplasia / Q000628:therapy*; D001999:Bronchoscopy; D000072700:Conservative Treatment; D004108:Dilatation, Pathologic / Q000000981:diagnostic imaging / Q000628:therapy; D005260:Female; D006801:Humans; D007223:Infant; D007234:Infant, Premature; D015278:Intensive Care Units, Pediatric; D007828:Laryngoscopy; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000628:therapy*; D012119:Respiration; D012121:Respiration, Artificial / Q000379:methods*; D014057:Tomography, X-Ray Computed; D014132:Trachea / Q000601:surgery; D014133:Tracheal Diseases / Q000000981:diagnostic imaging / Q000628:therapy*; D055090:Tracheomalacia / Q000628:therapy; D014139:Tracheostomy / Q000009:adverse effects*
keywords: Airway; Complications; Conservative management; Erosion; Tracheal false pouch; Tracheostomy