Rapidly progressive air leak syndrome after uneventful extubation in a pediatric patient: a case report

Air leak syndrome following uneventful extubation is rare in pediatric patients undergoing nonthoracic surgery; however, it can lead to rapid airway compromise and respiratory failure.

A previously healthy 8-year-old girl developed rapidly progressive generalized subcutaneous emphysema and dyspnea shortly after extubation following surgery for a right radial fracture. Intraoperative intubation was uneventful, the peak airway pressure remained within normal limits, and extubation proceeded with no coughing or bucking. After transfer to the ward, the oxygen saturation declined to 40%. Manual ventilation through a supraglottic airway device was associated with high resistance and air leakage. On arrival at the emergency department, severe cervicofacial swelling from subcutaneous emphysema precluded videolaryngoscopic intubation. Endotracheal intubation was eventually achieved with a Cormack-Lehane grade IV view. Imaging revealed extensive subcutaneous emphysema, pneumomediastinum, and bilateral pneumothorax. Needle decompression and bilateral chest tube insertion were conducted immediately, followed by mechanical ventilation in the intensive care unit. Bronchoscopy revealed no definite tracheobronchial injuries. The patient recovered without complications.

Rapidly progressive air leak syndrome should be considered in children who develop neck swelling or unexplained respiratory distress shortly after extubation. Repeated forceful ventilation should be avoided when ventilation is ineffective and airway control should not be delayed.