Massive subcutaneous emphysema following bronchoscopy-guided percutaneous dilatational tracheostomy

Although percutaneous dilatational tracheostomy (PDT) has become a safe procedure for airway management in critically ill patients, this operation can be associated with serious life-threatening complications. Massive subcutaneous emphysema is an unusual and sometimes lethal complication which may extend the length of stay in the intensive care unit (ICU). We report 2 cases, including 1 fatality, of massive subcutaneous emphysema without tracheal wall laceration that occurred in the ICU after elective bronchoscopy-guided Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IL, USA) PDT. Our analysis of these cases suggested that PDT-related barotraumas and imperfect positioning of the fenestrated tracheostomy tube could be the possible mechanisms for the observed complications. In case 1, we reduced the ventilator pressure and prescribed bronchodilator to decrease the airway pressure and keep the airway patent. In case 2, the suggested approach was to check if the fenestration of tracheostomy tube was extraluminal or change to non-fenestrating cannulas. For diminishing the impact of PDT on respiratory mechanics, especially in patients with underlying lung diseases, we recommend introducing the bronchoscope only when needed, instead of keeping the bronchoscope in the airway throughout the PDT procedure and using forceps to create a larger stoma if the dilation procedure is not smooth.