Perforation of the trachea by an endotracheal tube: an autopsy case

An 80-year-old woman was intubated with a spiral endotracheal tube via a tracheal stoma during an arytenoidectomy. After being connected to the ventilator, the victim quickly became cyanosed, showed a decrease in blood pressure, and fell into cardiopulmonary arrest. Despite continuous resuscitation, the victim died. Necropsy found a tracheal perforation located 2.0 cm distal from the tracheal stoma that led to the right pleural space through the mediastinal space. We concluded that the tip of spiral endotracheal tube passed through the membranous part of the trachea into the pleural space and caused a hemopneumothorax followed by blood aspiration and death. Tracheal perforation is a rare, but life-threatening complication following a tracheostomal intubation. The inappropriate use of a tracheal tube stylet, guiding catheter, dilating forceps, and oversize tracheal tube have been demonstrated to cause airway injuries. However, fatal incorrect intubation with a spiral endotracheal tube via a tracheal stoma that resulted in death has not been reported previously.