Tracheostomy Tube Change Versus PEEP Titration on Tracheostomy‐Dependent Infants With Airway Malacia and Ventilator Instability

Abstract

Objective

To investigate the impact of positive end‐expiratory pressure (PEEP) titrations or tracheostomy size change (trach change) on ventilation stability in infants with tracheobronchomalacia.

Study Design

A retrospective chart review.

Setting

Tertiary care children's hospital from 2015 to 2023.

Methods

A retrospective chart review on ventilator and tracheostomy‐dependent patients <1 year of age. Demographics, bronchoscopic findings, and ventilator outcomes within 14 days were recorded. Analysis was performed with chi‐square, Fisher's exact, binomial regression analysis, and two‐tailed t tests.

Results

Of 71 patients (66% male, median 6.1 months old [interquartile range, IQR, 4.6‐7.3]) who underwent 74 initial bronchoscopies, the PEEP titration cohort (n = 37) experienced an improvement (narrower) in 24‐hour mean ventilatory ranges (peak inspiratory pressure [PIP] 5.6 pre vs 2.9 post, P = .01; fraction of inspired oxygen [FiO₂] range 5% vs 3%, P = .04), whereas the trach change cohort did not (PEEP 5.9 vs 5.6, P = .8; FiO₂ 10% vs 5%, P = .07). In patients with airway malacia, the PEEP titration cohort had improved PIP ranges postintervention (5.5 vs 3.0, P = .02), whereas the trach change cohort did not (4.4 vs 6.6, P = .13). In patients without airway malacia, trach change correlated with improved PIP (8.4 vs 3.8, P = .04). Repeat bronchoscopy after initial intervention was significantly more common after trach change compared to PEEP titration (22% vs 3%, P = .01).

Conclusion

PEEP titration was associated with improved PIP and FiO₂ ventilatory outcomes with a lower rate of repeat bronchoscopy compared to trach change, suggesting trach change alone may have little impact with greater subsequent interventional needs compared to PEEP titration.

Pediatric tracheobronchomalacia (TBM) is a condition of dynamic airway collapsibility that may be concurrent with or secondary to other congenital abnormalities. ¹ , ² The tracheobronchial tree contains areas of immature cartilage, which are subject to collapse, causing a decreased cross‐sectional area. ³ The collapse can be further characterized by distal‐proximal localization of the disease (tracheomalacia, bronchomalacia, or TBM) and axial localization (anterior, posterior, or lateral malacia). ⁴

Clinical manifestations of TBM vary from being clinically asymptomatic to respiratory distress requiring mechanical ventilation. Due to the small cross‐sectional area of infant/premature airways, this population is prone to having symptomatic disease from increased airflow resistance with minute changes in radius. ⁵ , ⁶ This can be compounded by other concomitant respiratory diseases, often concurrent with airway malacia such as bronchopulmonary dysplasia (BPD). ² The natural progression of TBM is self‐resolution with time and growth, but artificial support may be needed until cartilaginous and pulmonary maturity. ⁴ , ⁶

Standard management for infants needing mechanical ventilation for TBM often necessitates tracheostomy. However, tracheostomy‐dependent patients are prone to episodes of ventilatory instability where intermittent desaturation or inspiratory pressure variability necessitates resuscitation. Management of ventilatory instability in tracheostomy‐ and ventilation‐dependent patients is variable across practices. There is a paucity of data on which interventions are most beneficial. Our institutional practice involves flexible tracheobronchoscopy to characterize airway abnormalities in symptomatic patients to direct interventions, which entails positive end‐expiratory pressure (PEEP) titration, tracheostomy tube size change (trach change), medication addition, or otolaryngologic operative interventions. From our internal investigation of flexible tracheobronchoscopy outcomes in pediatric patients with ventilatory instability, the proportion of patients undergoing PEEP titration versus trach change was comparable without clear evidence of which interventions are most impactful, especially in infants.

The goal of this study was to determine the utility of PEEP titration versus trach change on ventilatory stability in symptomatic ventilator‐dependent infants with tracheostomy. We hypothesized that PEEP titration may be more useful than trach change in the management of ventilation instability in patients with airway malacia.

Methods

A retrospective chart review at a tertiary care pediatric hospital on patients <1 year of age with ventilatory and tracheostomy dependence who underwent flexible tracheobronchoscopy between January 2015 and January 2023 was performed. Bedside flexible tracheobronchoscopy was performed via the tracheostomy tube to evaluate the distal tracheobronchial tree. Ventilatory instability was defined as episodes of ventilatory setting variation requiring intervention including frequent desaturation and/or increasing ventilatory pressures. Exclusion criteria included patients >1 year postgestation, those not requiring mechanical ventilation, those without a tracheostomy at the time of intervention, performance of tracheobronchoscopy for nonventilatory instability purposes, and if neither PEEP titration nor trach change was performed. The first flexible bronchoscopy for each admission for ventilatory instability was identified as a unique event. Patients who received both PEEP and trach change were excluded from comparative analyses.

Variables collected include age, sex, birth weight, gestational age at birth, nonmalacic medical comorbidities, 24‐hour preinterventional ventilatory settings (including PEEP, maximum and minimum peak inspiratory pressure [24‐hour PIP], and maximum and minimum fraction of inspired oxygen [24‐hour FiO₂] range, and tracheostomy data (tracheostomy tube type, size, and date of tracheostomy). Flexible bronchoscopy data collected included bronchoscopy indication, malacia location, and PEEP settings. Patients were categorized by their intervention group of PEEP titration versus trach change.

The primary outcome was ventilation settings at 14 days postbronchoscopy. Secondary outcomes were the need for subsequent tracheobronchoscopy and hospital status improvement, defined as the patient being downgraded from the intensive care unit (ICU) to the floor or hospital discharge within 14 days of the intervention. Ventilation and secondary clinical outcomes were collected at 14 days postbronchoscopy to allow adequate time for the effect of treatment to stabilize.

Statistical analyses on categorical variables were performed utilizing binomial logistic regression, chi‐square comparison of proportion analysis, or Fisher's exact test. Comparison of continuous variables, including postbronchoscopic intervention comparison including ventilatory changes, was performed utilizing paired two‐tailed Student's t test for independent means, two‐sample t test assuming unequal variances, and linear regression analysis. All calculations were performed utilizing IBM SPSS Statistics for Windows, Version 28.0. ⁷ This study received institutional review board approval from all institutions before initiation.

Results

There were 88 patients (66% male) who underwent 104 flexible tracheobronchoscopies for ventilatory instability (about 1.1 ± 0.3 bronchoscopies per admission). Sixteen patients had more than one hospital admission. There were 91 bronchoscopies considered to be the initial bronchoscopy per admission. Of these, 37 trach changes occurred without concurrent PEEP titration in 37 patients, and 37 PEEP titrations without concurrent trach change occurred in 36 patients. There were 17 patients who underwent 17 PEEP titrations with a concomitant trach change within 14 days, and these patients were excluded from further analyses. In total, 74 interventions were included for analysis (Table 1).

Table 1.

Patient and Airway Characteristics of Tracheostomy‐ and Ventilation‐Dependent Infants With Ventilation Instability That Received Tracheostomy Tube Change or Positive End‐Expiratory Pressure (PEEP) Titration

Characteristic	Value, N (%)
No. of patients	71
Median gestational age, wk (IQR)	28 (IQR 25‐36)
Mean birth weight, kg	1.4 ± 1.1
Medical comorbidity
Bronchopulmonary dysplasia (BPD)	68 (96%)
Congenital heart disease	17 (24%)
Pulmonary hypertension	22 (31%)
Congenital skeletomuscular condition	7 (10%)
Congenital cerebrospinal abnormality	7 (10%)
Trisomy 21	4 (6%)
Other syndromic/genetic conditions	5 (7%)
No. of initial flexible tracheobronchoscopy	74
Median age at time of bronchoscopy, mo (IQR)	6.1 (4.6‐7.3)
Mean time from tracheostomy to bronchoscopy, mo (STD)	1.8 ± 1.8
Indications for tracheobronchoscopy
Frequent desaturation	38 (51%)
Increasing PEEP requirement	11 (15%)
Increasing PIP or FiO2 requirement	9 (12%)
Postbronchoscopy interventions
PEEP adjustment	37 (50%)
Tracheostomy tube size change	37 (50%)
No. of patients with airway malacia	60
Only tracheomalacia	12 (20%)
Only bronchomalacia	16 (27%)
Tracheobronchomalacia	32 (53%)
Any bronchomalacia	48 (80%)
Right	4 (8%)
Left	15 (31%)
Bilateral	29 (60%)
Any tracheomalacia	44 (73%)

Abbreviations: FiO₂, fraction of inspired oxygen; IQR, interquartile range; PIP, peak inspiratory pressure; STD, standard deviation.

Median gestational age and mean birth weight were 28 weeks (interquartile range [IQR] 25‐36) and 1.4 ± 1.1 kg, respectively (Table 1). The average time from tracheostomy to tracheobronchoscopy for ventilatory instability was 1.6 ± 1.7 months. Median age and weight at time of endoscopy were 6.1 months (IQR 4.6‐7.3) and 6.2 kg (IQR 5.3‐7.0), respectively. The three most common comorbidities were BPD (96%), pulmonary hypertension (31%), and congenital heart disease (24%). The most common indications for bronchoscopy were frequent FiO₂ desaturations during stooling, feeding, and/or medication administration (51%), increasing PEEP requirements (15%), and increasing FiO₂ requirements (12%). No flexible or rigid tracheobronchoscopies were performed between the time of surgical tracheostomy and the studied tracheobronchoscopy. All tracheostomy tubes were Bivona® tight to shaft™ cuffed tubes.

In the trach change‐only cohort, the average trach length change was +0.8 ± 0.3 cm with an average outer diameter change of 0.2 ± 0.3 mm. Custom‐length tracheostomies were placed in 65% of these patients. All patients received a single tracheostomy tube exchange during the studied time interval. In the PEEP titration‐only cohort, average PEEP titration change was +1.9 ± 2.1 cm H₂O with 33 (89%) requiring an increase in PEEP. Earlier gestational age was associated with an increased rate of tracheostomy change, where with each week earlier a patient was born, they were 7% more likely to receive a tracheostomy change (odds ratio [OR] = 0.93, 95% CI [0.88, 0.99]). The history of BPD was associated with an increased rate of repeat bronchoscopy after trach change or PEEP titration compared to non‐BPD counterparts (17% vs 2.7%, P = .03). No other demographic variable was associated with intervention type.

Ventilation Outcomes

Before tracheobronchoscopy, average 24‐hour PIP ranges did not differ between the PEEP titration and trach change cohorts (5.6 vs 5.9, P = .8). Postintervention, the average 24‐hour PIP range was significantly lower in the PEEP titration cohort compared to the trach change group (2.9 vs 5.6, P = .04). Overall, the PEEP titration cohort experienced a significant improvement (narrower) in the average 24‐hour PIP range after intervention (5.6 pre vs 2.9 post, P = .01), whereas the trach change cohort did not (5.9 vs 5.6, P = .8).

Before tracheobronchoscopy, the average 24‐hour FiO₂ range was significantly wider in the trach change cohort compared to the PEEP change group (10% vs 5%, P = .03). Postintervention, the 24‐hour FiO₂ range did not significantly differ between the cohorts (5% vs 3%, P = .09). Within the PEEP titration group, 24‐hour FiO₂ ranges significantly improved 14 days after intervention (5% vs 3%, P = .04) whereas the changes were not found to be significant in the trach change group (10% vs 5%, P = .07) (Table 2).

Table 2.

Ventilatory Outcomes 14 Days After Tracheostomy Tube Change Versus Positive End‐Expiratory Pressure (PEEP) Adjustment in Symptomatic Infants With Chronic Tracheostomy and Mechanical Ventilation ^a

	Average 24‐h PIP range, cm H2O			Average 24‐h FiO2 range
Group	Baseline	After	P (95% CI)	Baseline, %	After, %	P (95% CI)
Trach change	5.9	5.6	.8 (−3.2 to 2.7)	3	5	.07 (0.0‐0.08)
PEEP titration	5.6	2.9	.01 (0.5‐4.8)	5	3	.04 (0.0‐0.1)

Abbreviations: CI, confidence interval; FiO₂, fraction of inspired oxygen; PIP, peak inspiratory pressure.

^a P < .05 statistically significant.

Airway Malacia Relations

Airway malacia was characterized in the 74 initial tracheobronchoscopies (Table 1). Tracheomalacia alone was noted in 12 (16%) cases, bronchomalacia alone in 16 (22%), TBM in 32 (43%), and no malacia in 14 (19%) patients. Of the 48 patients with any bronchomalacia present, pathology was present in bilateral bronchi (60%), right mainstem bronchus (8%), and left mainstem bronchus (31%). Patients with any airway malacia were significantly more likely to receive PEEP titration compared to trach change (60% vs 40%, P = .03). Patients with any bronchomalacia were significantly more likely to receive PEEP titration compared to trach change (29% vs 71%, P < .01). Patients with any tracheomalacia did not correlate with undergoing either PEEP titration or trach change more often (44% vs 56%, P = .17) (Table 3).

Table 3.

Airway Malacia and Average 24‐Hour PIP Ranges Before and After Positive End‐Expiratory Pressure (PEEP) Titration Versus Trach Change in Tracheostomy‐ and Ventilatory‐Dependent Infants ^a

	PEEP adjustment (n, cm H2O)			Tracheostomy tube change
Airway malacia	Before	After	P (95% CI)	Before	After	P (95% CI)
Any airway malacia	5.5	3.0	.02 (0.4‐4.6)	4.4	6.6	.13 (−5.0 to 0.7)
Tracheobronchomalacia	5.3	2.3	.03 (0.3‐5.6)	5.4	4.3	.65 (−4.7 to 7.0)
Only bronchomalacia	6.6	3.6	.13 (−1.1 to 7.1)	6.5	11.2	.06 (−9.5 to 0.2)
Any bronchomalacia	5.7	2.7	.01 (0.9‐5.1)	5.9	7.5	.38 (−5.2 to 2.2)
Only tracheomalacia	‐	‐	‐	2.5	5.5	.23 (−8.2 to 2.2)
Any tracheomalacia	5.1	2.8	.09 (−0.4 to 4.9)	3.7	5	.46 (−4.9 to 2.3)
No airway malacia	‐	‐	‐	8.4	3.8	.04 (0.1‐8.9)

Abbreviation: CI, confidence interval.

^a P < .05 statistically significant.

In patients with any airway malacia, the PEEP titration cohort had significantly improved average PIP ranges postintervention (5.5 vs 3.0, P = .02), whereas the trach change cohort did not (4.4 vs 6.6, P = .13). When evaluating patients with any bronchomalacia (bronchomalacia only and TBM cohorts), patients were found to have improved PIP ranges at 14 days in the PEEP titration cohort (5.7 vs 2.7, P = .01) but not in the trach change cohort (5.9 vs 7.5, P = .38). In patients with any tracheomalacia (tracheomalacia only and TBM cohorts), PIP ranges did not significantly differ after either PEEP titration (5.1 vs 2.8, P = .09) or trach change (3.7 vs 5.0, P = .46). FiO₂ variability was not found to be narrower in the any airway malacia, any bronchomalacia, or any tracheomalacia cohorts.

In the 12 patients with only tracheomalacia, there were 10 (63%) trach change events with an average tracheostomy size change of +0.8 ± 0.3 cm in length and +0.1 ± 0.3 mm in outer diameter. No one received a shorter trach tube. Two (13%) patients underwent PEEP change, with both patients requiring uptitration by 2 cm H₂O. Trach change was not associated with improved PIP variability (2.5 vs 5.5, P = .23) or FiO₂ variability (6% vs 5%, P = .61) at 14 days. Low PEEP change sample size prohibited preintervention versus postintervention calculation.

In the 16 patients with only bronchomalacia, there were 6 (38%) trach changes with an average trach size change of +0.7 ± 0.4 cm in length and +0.1 ± 0.3 mm in outer diameter. There were 10 (63%) PEEP titrations with an average change of +1.4 ± 2.0 cm H₂O. Trach change was not significantly associated with improved PIP variability (6.5 vs 11.2, P = .06) or FiO₂ variability (16% vs 8%, P = .19) at 14 days. PEEP change was not significantly associated with improved PIP variability (6.6 vs 3.6, P = .13) or FiO₂ variability (3% vs 3%, P = .92).

In the 32 patients with TBM, there were 8 (25%) trach changes with an average tracheostomy tube length change of +0.7 ± 0.3 cm and outer diameter change of +0.3 ± 0.3 mm. There were 24 (75%) PEEP titrations with an average PEEP uptitration of 2.1 ± 2.3 cm H₂O. Patients were found to have improved average PIP ranges after PEEP titration (5.3 vs 2.3, P = .03) but not after trach change (5.4 vs 4.3, P = .65). FiO₂ was not significantly changed either PEEP titration cohort (6.2% vs 2.7%, P = .06) or trach change cohort (4.2% vs 2.8%, P = .35).

In the 14 patients without airway malacia, there were 13 (93%) trach changes with an average tracheostomy tube length change of +0.5 ± 0.7 cm and outer diameter change of +0.2 ± 0.3 mm. There was only 1 (7%) PEEP change with uptitration by 2.0 cm H₂O. Trach change correlated with improved PIP range in this group (8.4 vs 3.8, P = .04) but not improved FiO₂ range (12% vs 7%, P = .3). The singular case of PEEP titration precluded further statistical analysis of the impact of intervention type on ventilation outcomes.

Secondary Clinical Outcomes

Thirty‐two (35%) patients had hospital status improvement within 14 days of trach change or PEEP titration. Neither intervention group was associated with hospital status improvement at 14 days. Nine (12%) repeat tracheobronchoscopies in nine patients were performed with five subsequent trach changes and three further PEEP titrations. Eight repeat bronchoscopies occurred after a trach change, whereas one occurred after a PEEP titration. No comorbidity was associated with an increased rate of either intervention. Need for repeat bronchoscopy after initial intervention was significantly more common in the trach change group compared to the PEEP change group (22% vs 3%, P = .01).

Discussion

TBM in mechanically ventilated infants remains a clinical challenge requiring multidisciplinary care between the ICU, pulmonology, and otolaryngology teams. Although the natural progression of disease typically shows improvement with time, some patients require tracheostomy to allow for multiple years of mechanical ventilation. ⁸ , ⁹ , ¹⁰ During this period of watchful management, patients often struggle with ventilatory instability requiring bedside or operative intervention. The patient population of this study is of particular interest as studies have shown tracheostomy to be prevalent in pediatric patients early in life with concomitant respiratory pathology such as BPD and prematurity. ⁸ , ⁹

PIP is the maximal pressure supplied during the delivery of a breath during mechanical ventilation and is often used as a surrogate measure of airway resistance. PEEP serves to maintain airway patency at the end of the breath cycle. Poiseuille's law describes factors that affect airflow in an infant airway: Q = Δpπr ⁴/8μL, where Q is the flow rate of air through the airway, ΔP is the pressure differential between proximal and distal airway, L is the length of the airway, and r represents the radius of the airway. The μ (fluid dynamic viscosity) of the delivered air is considered constant, although this can be modified when using heliox or other low viscosity gases. Resistance of airflow (R), defined by R = 8μL/πr ⁴, is inversely proportional to Q. Changes in radius have the greatest unit‐effect on airflow dynamics. Each unit increase results in a change in resistance by a power of four. Airway malacia directly affects the radius of the airway at multiple locations, thereby significantly increasing airway resistance, necessitating higher ΔP (or PIP) to maintain adequate airflow. ⁴ , ¹¹ Reducing maximal pressures, as well as the variability of these pressures, theoretically reduces the atelectotrauma associated with the chronic opening and closure of the alveoli. ¹² , ¹³ This is particularly important in conditions involving preexisting airway instability, such as BPD and airway malacia, as this atelectotrauma is thought to be a major contributing factor associated with ventilator‐induced lung injury. ¹⁰ , ¹³ , ¹⁴

In this study, the authors sought to determine the relationship of ventilatory settings after PEEP adjustments versus placement of a longer and/or wider tracheostomy tube in infants symptomatic with ventilatory instability. A longer tracheostomy tube can reduce longitudinal areas of collapse within the trachea by rigid stenting, improving the cross‐sectional area of the proximal airway and thus proximal airflow. PEEP adjustments also provide radial improvement and can have a more distal impact on maintaining bronchial and alveolar patency throughout the respiratory cycle. A higher PEEP may lead to lower PIP requirements by enabling airway patency during times of rest and periods of activity. ¹⁰ , ¹⁴ , ¹⁵ However, unlike with rigid stenting with a tracheostomy tube, the airway can still be subjected to some degree of collapse from dynamic pressure variances with patient behaviors such as Valsalva maneuvers, and there is a risk of barotrauma with increasing PEEP values.

This study indicated that PEEP modification was associated with greater ventilatory stability compared to trach size change. Our subgroup analyses on airway malacia types suggested that ventilatory improvements after PEEP titration were influenced most by patients with bronchomalacia, as indicated by improved outcomes in patients with any bronchomalacia and TBM. Interestingly, the cohort with only bronchomalacia demonstrated narrower PIP ranges after PEEP titration but did not reach statistical significance. This may be due to low sample size and power. Another explanation involves patients with TBM being more affected by longer areas of collapse over the distal tracheobronchial tree compared to more focal areas in only bronchomalacia cases. In contrast, tracheomalacia was not a prognosticating factor in either intervention group. Our results imply that the small change in airway radius and length by a new tracheostomy tube appears less impactful than addressing the combined tracheobronchial tree via PEEP titration for infants with known distal airway collapse.

Consistent pressure support and maintenance of airway patency provide consistent oxygen delivery by way of giving full, unhindered breaths. Regarding FiO₂ outcomes, using lower FiO₂ is favored in chronically ventilated infants. Studies have shown that abnormal levels of oxygenation may chronically alter the hypoxic respiratory response, which can worsen ventilatory mechanics and breath delivery. ¹⁶ Minimizing oxygen requirements has also been shown to improve outcomes; 21% FiO₂ oxygen challenges being performed at set points during infant hospital stays have been correlated with improved length of stay in infants with prematurity. For these reasons, maintaining a consistently low FiO₂ with high PEEP delivery has become standard of care compared to using low PEEP and high FiO₂. ¹⁰ , ¹⁶ , ¹⁷ , ¹⁸ Our results indicate that PEEP titration is associated with improved FiO₂ variability compared to trach change, which indicates more consistent oxygenation at a predictable level.

Interestingly, tracheostomy size change showed an overall worsening of PIP values in the malacia groups, although this did not reach statistical significance. Tracheostomy change was shown to improve postintervention PIP variability in patients without airway malacia, although comparison between trach change and PEEP titration groups was not possible due to low sample sizes in the PEEP titration cohort. The role of trach changes remains unclear but may provide benefit in patients with focal tracheal collapse if pathological segments are able to be stented by the longer tracheostomy tube. Data remain limited on optimal timing and indications for trach change in the infant patient population. Our study suggests that trach tube upsizing in periods of ventilatory instability within 3 months of tracheostomy surgery, while a common practice, may not be an effective first‐line treatment in achieving ventilatory goals in infant populations with known TBM. More studies are needed to determine optimal timing and patient population.

No intervention was associated with improved hospital status at 14 days. This is likely multifactorial in nature as our patient population may have other comorbidities that prohibit ICU discharge. The improvement in PIP and/or FiO₂ may not correlate with settings low enough to allow transition to home ventilatory systems for the floor or for discharge. Additionally, there was a high proportion of patients receiving repeat bronchoscopy after trach change compared to after PEEP titration. Although PEEP titration provides real‐time feedback on airway patency improvement at the time of the bronchoscopy, tracheostomy change is often associated with repeat tracheobronchoscopy to confirm appropriate position and distance from the carina. Custom trach tubes, which accounted for 65% of our trach change cohort, also necessitate additional time and cost to procure. Avoiding unnecessary trach tube size changes and contingent interventions may present a resource‐ and cost‐saving measure.

Limitations of this study reside in the retrospective review, which limits cohort randomization and population equivalency/representation between groups. Causal relationships cannot be adequately inferred in retrospective studies as compared to prospective ones. Chart review may limit the outcomes of this study, as there may have been performed interventions or resultant outcomes that were not adequately charted. Additionally, our analyses were limited when substratifying airway malacia patterns due to an overall low sample size. PEEP titration is an inherently subjective intervention and may lend itself to interpractitioner variability. Combination of trach change with PEEP titration is a possible intervention that may result in different or improved outcomes compared to trach change or PEEP titration alone. Our practice pattern generally entailed a stepwise approach in performing single interventions at a time. Therefore, the sample size of patients who underwent both trach change and PEEP titration was small and not adequately powered for comparative analysis in this patient population. This remains an area of interest and potential further study. Further evaluation with prospective studies would provide further insight into outcomes and causal relationships.

Conclusion

Ventilatory instability remains clinically challenging for practitioners managing tracheostomy‐dependent and mechanically ventilated infants. PEEP adjustments at the time of investigational bedside tracheoscopy are associated with improved ventilatory stability compared to tracheostomy change in infants with TBM.

Author Contributions

Harrison M. Thompson, conceptualization, data collection, writer; Mikayla Hubbard, data collection; Johnny Krasinkiewicz, conceptualization, data collection; Sarah E. Bauer, conceptualization, data collection, editor; Diane W. Chen, conceptualization, data collection, writer, editor.

Disclosures

Competing interests

None.

Funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.