Management of Massive Post-Tracheostomy Subcutaneous Emphysema With an Adjustable-Length, Wire-Reinforced...

Massive subcutaneous emphysema with pneumomediastinum is a rare but potentially life-threatening complication following tracheostomy, for which standardized management strategies are lacking. We report the case of a 67-year-old man who developed progressive cervicofacial and thoracic subcutaneous emphysema on postoperative Day 9 after an otherwise uncomplicated surgical tracheostomy using a fenestrated tube. The tracheostomy had been performed after multiple failed extubation attempts due to Type 2 respiratory failure in the setting of interstitial lung disease. Diagnostic evaluation with fiberoptic tracheoscopy and computed tomography of the neck and chest demonstrated extensive subcutaneous emphysema, pneumomediastinum, tracheal dilation, a suspected persistent air leak related to tube-trachea size mismatch, and the presence of fenestrations. Initial conservative bedside measures failed to halt progression. Subsequent exchange to a non-fenestrated, flexible, wire-reinforced cuffed tracheostomy tube with adjustable length resulted in rapid regression and complete resolution of the emphysema without the need for further intervention. This case highlights the importance of early recognition of anatomical and device-related contributors to post-tracheostomy air leak and demonstrates that prompt, targeted tracheostomy tube selection can provide effective airway sealing and obviate invasive management strategies.