primary tracheomalacia is a rare congenital condition characterized by weakness of tracheobronchial cartilaginous bridges , resulting in reduced tracheobronchial lumen . the following case report illustrates the various anesthetic concerns in the management of an infant undergoing aortopexy . a 2-month - old boy , weighing 2180 g , case of severe tracheomalacia was scheduled for aortopexy . the patient , born at 36 weeks of gestation , had undergone primary repair of tracheoesophageal fistula at 3 h of life , following which he had multiple failed attempts at extubation . all relevant investigations including chest x - ray and echocardiogram ( echo ) were normal . trachea was already intubated with a size 3.5-mm internal diameter uncuffed tracheal tube with oxygen supplementation via t piece . after establishing standard monitors [ electrocardiogram ( ecg ) , non - invasive blood pressure ( nibp ) , spo2 , end - tidal carbon dioxide ( etco2 ) ] , injection ranitidine 2.5 mg , metoclopromide 0.3 mg , dexamethasone 1.2 mg , and fentanyl 4 mcg were administered intravenously . patient s spontaneous respiratory efforts were maintained for dynamic assessment of tracheomalacia . a neonatal flexible fiberoptic bronchoscope ( size 2.2 mm ) the tracheal tube was then withdrawn over the bronchoscope to allow for assessment of trachea . the anterior tracheal wall near carina was seen to collapse with inspiration . following assessment , the tracheal tube was reinserted into the trachea by railroading over the bronchoscope . left anterior third intercostal space thoracotomy was done . during dissection , the patient had an episode of hypotension and bradycardia ( up to 70/min ) . after the surgical procedure was complete , neuromuscular block was reversed with injection glycopyrolate 0.02 mg and injection neostigmine 0.15 mg intravenously . morphine 0.06 mg via caudal route and paracetamol suppository 80 mg were given for postoperative analgesia . trachea was extubated and patient was able to breathe normally . throughout the intraoperative period , tracheobronchomalacia is a rare disease characterized by abnormal softness or absence of bronchotracheal cartilaginous bridges , resulting in reduced tracheobronchial lumen . primary or congenital tracheomalacia is usually associated with esophageal atresia and tracheoesophageal fistula . secondary or acquired tracheomalacia usually follows prolonged compression of the trachea by tumors , vascular malformations , or following long - standing intubation or tracheostomy . the disease process may involve the entire length of the trachea or only small segments of the tracheobronchial tree , producing varying degrees of airway obstruction . in primary tracheomalacia , symptoms typically develop in early infancy but may present later also . while mild cases resolve spontaneously or with conservative measures , severe cases causing life - threatening airway obstruction require surgical intervention . aortopexy is an accepted and safe procedure for the treatment of severe tracheomalacia in infancy . aortopexy may be performed either via a right or left anterior thoracotomy or as minimally invasive thoracoscopic aortopexy . the procedure involves placement of sutures in the adventitia of the ascending aorta and through the posterior periosteum of the sternum , bringing forward the aortic root to the sternum , thus widening the tracheal diameter . most patients undergoing this procedure are infants or children , with corresponding concerns of pediatric anesthesia . tracheomalacia may be associated with esophageal atresia , tracheoesophageal fistula , and gastroesophageal reflux , which need to be managed appropriately . intraoperative bronchoscopic monitoring may be required to control the amount and direction of aortopexy for assuring the most effective tracheal decompression . since tracheomalacia is best assessed in a spontaneously breathing patient , it is an anesthetic challenge to maintain an adequate depth of anesthesia while allowing the patient to breathe spontaneously . moreover , the anesthesiologist must ensure adequate oxygenation during bronchoscopy . introducing the fiberoptic bronchoscope through the tracheal tube and then withdrawing the tracheal tube over the bronchoscope for assessment of the trachea secondly , once bronchoscopic assessment is complete , the tracheal tube can be immediately reinserted into the trachea by railroading over the bronchoscope . this decreases the time during which the airway is not secure , as well as the number of airway manipulations . it is prudent to use steroids for premedication as well as postoperative inhalational steroids to decrease airway edema and reactivity owing to repeated airway manipulations , especially in infants with already narrow airways . it is imperative to maintain an adequate preload and depth of anesthesia to minimize the occurrence of such episodes . although we did not secure an arterial access in this patient , it would be prudent to do so in any such future cases as it can help to monitor the blood gas levels and blood pressure more accurately . intraoperative bronchoscopic monitoring may be required to guide the direction and amount of aortopexy for assuring the most effective tracheal decompression , during which it is best to maintain spontaneous respiration . intravenous and inhalational steroids are warranted in the peri - operative period to reduce airway reactivity and edema . a team approach by surgeon , anesthesiologist , and pediatrician is a must to ensure good outcome .
tracheomalacia is a rare condition characterized by weakness of tracheobronchial cartilaginous bridges . 
 severe weakness results in tracheal collapse during inspiration , obstructing normal airflow . 
 tracheomalacia may also be associated with esophageal atresia , tracheoesophageal fistula , and gastroesophageal reflux . 
 aortopexy is an established surgical procedure for treatment of severe tracheomalacia . 
 a 2-month - old boy was scheduled for aortopexy . 
 he had already undergone repair of tracheoesophageal fistula and had failed multiple attempts at extubation . 
 intraoperative flexible fiberoptic bronchoscopy was performed to guide the amount and direction of aortopexy for assuring the most effective tracheal decompression . since tracheomalacia is best assessed in a spontaneously breathing patient , it was an anesthetic challenge to maintain an adequate depth of anesthesia while allowing the patient to breathe spontaneously . throughout the intraoperative period , 
 spo2 remained 96% . 
 following the procedure , the trachea was extubated and patient was able to breathe normally .