Progressive Extension of a Post-intubation Tracheal Laceration Presenting As Massive Pneumomediastinum: A Case Report

Post-intubation tracheal laceration is rare and is usually managed conservatively, provided the tear is protected from positive pressure, whether by spontaneous ventilation, by a cuff sited beyond the lesion, or by ventilation delivered without loss of tidal volume. We describe a woman in her early 70s intubated at a district hospital for progressive impairment of consciousness. Imaging before intubation already showed a hiatal hernia, right bronchial mucous plugging, lobar consolidation and bilateral effusions, and initial ventilation delivered 500 mL at a rate of 18 per minute, approximately 9.5 mL/kg of predicted body weight, with an arterial carbon dioxide tension of 28 mmHg. No subcutaneous emphysema was documented before transfer. She arrived at a tertiary unit failing to achieve adequate tidal volumes, with an air leak unresponsive to cuff inflation and extensive cervicothoracic subcutaneous emphysema. The tube was exchanged, and the leak persisted, indicating an airway wall defect. Bronchoscopy showed a longitudinal tear of the posterior membranous trachea, visually estimated at approximately 4 cm and confined to the intrathoracic trachea, with no injury below the tube, and computed tomography confirmed diffuse pneumomediastinum without pneumothorax. The lesion was excluded by cuff position, although the seal varied with head position. Because an unresolved coma made positive-pressure ventilation unavoidable, repair was undertaken. At thoracotomy the following day, the laceration ran from 1 cm above the carina to the thoracic inlet with cervical extension, involving a segment where no injury had been seen the previous day, and the cervical component could not be reached. A persistent leak prompted tube exchange over an airway exchange catheter under simultaneous videolaryngoscopy; the catheter passed extraluminally through the unrepaired tear and the airway was lost. It was regained only after thoracotomy closure and repositioning supine, but desaturation during those attempts had progressed to cardiac arrest, and death was declared intraoperatively. A tracheal laceration may extend between endoscopic assessment and operation, and glottic visualisation does not prevent a false passage when a cervical tear remains unrepaired.