Tracheal rupture and the creation of a false passage after emergency intubation

Endotracheal intubation is a common emergency department procedure with rare but potentially life-threatening complications. A systematic review of the literature demonstrated that all patients with traumatic tracheal rupture after endotracheal intubation could be adequately ventilated despite tracheal perforation. We report an unusual case of tracheal perforation in which the patient could not be effectively ventilated because of the creation of a false passage caused by the endotracheal tube adjacent to the posterior wall of the trachea.