59: Percutaneous Tracheostomy Without Intubation or Positive Pressure Ventilation in a Patient with Bronchopleural Fistula on VV-ECMO: A Novel Airway Strategy”

Background: In patients with bronchopleural fistula (BPF), any form of positive pressure ventilation can worsen air leak, impair lung healing, and precipitate hemodynamic and gas exchange instability. Establishing a secure airway is especially challenging when conventional intubation or ventilatory support is contraindicated. Extracorporeal membrane oxygenation (ECMO) can provide a unique physiological bridge to allow airway intervention without positive pressure ventilation. Case Presentation: We report a young female 26-year-old admitted with community-acquired pneumonia suspected TB she had massive air leak with surgical emphysema after diagnostic bronchoscopy she developed a progressive respiratory failure. with failure of conventional ventilation secondary to severe dynamic air leak. VV-ECMO was initiated for CO2 removal and oxygenation support. During ECMO support, a definitive airway was required; however, tracheal intubation and positive pressure ventilation posed a high risk of worsening the fistula. Intervention: A percutaneous tracheostomy was successfully performed under fiberoptic bronchoscopy guidance without endotracheal intubation or positive pressure ventilation, using ECMO as the sole mode of gas exchange during the procedure. Continuous VV-ECMO flow maintained adequate oxygenation and ventilation throughout, allowing safe airway access while avoiding barotrauma and fistula expansion. Outcome: The patient remained stable perioperatively with no hypoxic or hemodynamic deterioration. The tracheostomy enabled improved airway toileting, secretion clearance, and respiratory stabilization. She still recieving her treatment on full VV-ECMO with weaning going on with preservation of neurologic function despite still no respiratory recovery yet. Conclusion: This case demonstrates that ventilation-free percutaneous tracheostomy is feasible and safe in carefully selected patients with bronchopleural fistula on VV-ECMO, where positive pressure ventilation is contraindicated. ECMO can serve not only as a respiratory bridge, but as an airway-protective platform enabling complex airway interventions with minimal physiologic risk.