Abstract
Tracheostomy is a common procedure seen in critically ill patients that require long term ventilatory support. As with all airway access procedures, tracheotomy with prolonged tracheal tube placement comes with possible risks such as tracheal scarring, tracheal rupture, pneumothorax, tracheoesophageal fistula among others. Another possible complication, though rare, is escape of free air into the surrounding tissue, as well as pneumomediastinum (PM). This may occur due to various reasons, some of them being tracheal rupture, barotrauma or tracheal tube mispositioning. Pneumomediastinum may present with concurrent free air in other body cavities such as the peritoneum, thorax or subcutaneous tissue. Though often not life-threatening it may require treatment including high flow oxygen, ventilator management or occasionally, surgical intervention. Herein we describe a rare case of PM with communicating pneumoperitoneum and massive subcutaneous emphysema due to tracheal tube mispositioning along with a review of the literature.
Highlights
Tracheostomy is often performed on critically ill patients usually after a prolonged period of mechanical ventilation via an endotracheal tube to facilitate weaning, improve patient comfort, and allow safe discharge from intensive care units [1]
We present a case of PM, pneumoperitoneum and massive subcutaneous emphysema in the setting of manipulation and mispositioning of a tracheostomy tube
Complications associated with tracheostomies are dependent on the time elapsed from the procedure with early complications being related to the immediate surgery including posterior tracheal wall injury, subcutaneous emphysema, tube dislodgement and tracheal tube obstruction [2]
Summary
Tracheostomy is often performed on critically ill patients usually after a prolonged period of mechanical ventilation via an endotracheal tube to facilitate weaning, improve patient comfort, and allow safe discharge from intensive care units [1]. CT of the chest showed what appeared to be a 7-mm linear gas density projecting from the posterior wall of the upper trachea which was not seen on tracheoscopy It showed extensive subcutaneous emphysema of the neck and thoracic walls, extensive PM, gas density surrounding the lungs within both the pleural and extra-pleural spaces, measuring 10 mm in the anterior lower right hemithorax and less than 10 mm in the anterior lower left hemithorax (Figure 2). CT of the abdomen and pelvis showed large pneumoperitoneum with posterior displacement of the viscera, numerous gas densities in the mesenteric fat and retroperitoneum, extensive subcutaneous emphysema in the soft tissues extending to the level of the labia and anterior thighs bilaterally (Figures 3, 4). Repeat chest X-ray 12 hours later showed a slight improvement in subcutaneous emphysema as less free air was evident in the soft tissue.
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