A Case of Pneumomediastinum and Pneumoperitoneum with Concurrent Massive Subcutaneous Emphysema due to Repositioning of a Tracheostomy Tube

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.

A Rare Yet Morbid Complication of Endotracheal Intubation: Tracheal Rupture

“…Deja et al [12] found that conservative management was preferred for patients who did not require mechanical ventilation and when their emphysema was only mild and stable during ventilation. Studies recommend that surgery is pursued for patients with posterior tracheal wall perforations greater than 2 cm and mainly depends on how proximal[ the injury is to the carina [14] . However, conservative treatment can still be managed in cases where there was no history of pulmonary or mediastinal surgery, as in our patient who underwent debridement for her right shoulder, and is increasingly becoming the mainstay of therapy.…”

“…However, conservative treatment can still be managed in cases where there was no history of pulmonary or mediastinal surgery, as in our patient who underwent debridement for her right shoulder, and is increasingly becoming the mainstay of therapy. A high concentration of oxygen is helpful for subcutaneous emphysema, and some cases have shown that 2-3 cm blowhole incisions in the supraclavicular or infraclavicular region are helpful for releasing subcutaneous air [14] . Other cases have shown that subcutaneous drains are successful at significantly reducing subcutaneous air and can be one of the methods implemented [14] .…”

“…A high concentration of oxygen is helpful for subcutaneous emphysema, and some cases have shown that 2-3 cm blowhole incisions in the supraclavicular or infraclavicular region are helpful for releasing subcutaneous air [14] . Other cases have shown that subcutaneous drains are successful at significantly reducing subcutaneous air and can be one of the methods implemented [14] .…”

Self-Inflicted Abdominal Air Insufflation Leading to Diffuse Subcutaneous Emphysema, Pneumoperitoneum, Pneumomediastinum, Pneumopericardium, and Pneumothorax: A Case Report

“…The air within the abdominal cavity may also lead to the development of air emboli via the introduction of air into the abdominal blood vessels or organs, possibly causing neurological damage or cardiovascular collapse [4]. Pneumomediastinum, pneumopericardium, and pneumoperitoneum may also occur in some scenarios as the fascia allows the passage of air between cavities [5][6][7]. No cases of intentional body insufflation have been documented in the literature to date.…”

An Intriguing Case of Pneumoperitoneum In a Patient With COVID-19: Do All Pneumoperitoneum Cases Need Surgery?

“…Pneumoperitoneum is characterized by the presence of abnormal gas (as air) in the potential abdominal space [1]. This usually is considered a surgical emergency and is associated with perforated abdominal viscus in more than 90% of cases [2][3][4].…”