This case report presents a 20-month-old boy with a history of prematurity, severe intrauterine growth restriction, and multiple comorbidities, including a tracheal bronchus, also known as a "pig bronchus." While tracheal bronchus is increasingly recognized as a more common anatomical variation, symptomatic cases, as seen in this patient, are rare. The condition, characterized by an accessory bronchus originating directly from the trachea, may be associated with recurrent pulmonary infections and can complicate respiratory management. In this case, the patient's chronic CO2 retention and oxygen requirement, particularly during sleep, were likely exacerbated by his underlying lung disease, with the tracheal bronchus potentially acting as an incidental finding. The management of symptomatic tracheal bronchus remains challenging due to the lack of large-scale, controlled studies. This case underscores the importance of a thorough differential diagnosis in pediatric patients with recurrent pulmonary infections and chronic respiratory symptoms, as well as the need for further research to establish standardized management guidelines for symptomatic tracheal bronchus.