• Frederick H Kuo, Richard A Elliott, Scott C Watkins, Hester F Shieh, Charles J Smithers, Russell W Jennings, and Munoz-San JulianCarlosCDepartment of Anesthesia, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA..
• Department of Anesthesia, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA.
• Paediatr Anaesth. 2024 Apr 1; 34 (4): 289292289-292.

BackgroundSurgical correction of tracheobronchomalacia (TBM) has evolved greatly over the past decade, with select pediatric institutions establishing dedicated surgery and anesthesia teams to navigate the complexities and challenges of surgical airway repairs. Although anesthetic techniques have evolved internally over many years to improve patient safety and outcomes, many of these methods remain undescribed in literature.TechniqueIn this article, we describe the intraoperative negative pressure suction test. This simulates the negative pressure seen in awake and spontaneously breathing patients, including the higher pressures seen during coughing which induce airway collapse in patients with TBM. Also known as the Munoz maneuver in surgical literature, this test has been performed on over 300 patients since 2015.DiscussionThe negative pressure suction test allows for controlled intraoperative assessment of surgical airway repairs, replaces the need for risky intraoperative wake-up tests, increases the chances of a successful surgical repair, and improves anesthetic management for emergence and extubation. We provide a guide on how to perform the test and videos demonstrating its efficacy in intraoperative airway evaluation.ConclusionsAs surgeries to repair TBM become more prevalent in other pediatric institutions, we believe that pediatric patients and anesthesia providers will benefit from the insights and methods described here.© 2023 John Wiley & Sons Ltd.

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