A tracheostomy tube (TT) is usually taken out in a well-planned and coordinated manner after the underlying condition that necessitated the procedure is resolved. The inadvertent removal or dislodgement of the TT from the stroma is known as accidental extubation or decannulation. This event may prove fatal in a stable patient. Like other respiratory procedures, tracheostomy with the long-term placement of tracheal tube comes with several risks, including scarring of the trachea, pneumothorax, tracheal rupture, and tracheoesophageal fistula. Other complications may include pneumomediastinum (PM) or the escape of air into the surrounding tissue. This may be attributed to several reasons, including mispositioning of the tracheal tube, barotrauma, or tracheal rupture. In some cases, PM presents with free air into cavities such as the thorax, peritoneum, or subcutaneous tissue. Although not fatal, it may require complex treatments such as ventilator management, high-flow oxygen, or, in some cases, surgical intervention. In this article, we describe a rare case of PM and generalized surgical emphysema due to mispositioning of the tracheal tube.

BACKGROUND: Trauma is one of the leading causes of death in the pediatric population. Bronchial rupture is rare, but there are potentially severe complications. Establishing and maintaining a patent airway is the key issue in patients with bronchial rupture. Here we describe an innovative method for maintaining a patent airway.
METHODS: A 3-year-old boy fell from the seventh floor. Oxygenation worsened rapidly with pulse oxygen saturation decreasing below 60%, as his heart rate dropped. Persistent pneumothorax was observed with insertion of the chest tube. Fiberoptic bronchoscopy was performed, which confirmed the diagnosis of bronchial rupture. A modified tracheal tube was inserted under the guidance of a fiberoptic bronchoscope. Pulse oxygen saturation improved from 60% to 90%. Twelve days after admission, right upper lobectomy was performed using bronchial stump suture by video-assisted thoracic surgery without complications. A follow-up chest radiograph showed good recovery. The child was discharged from hospital three months after admission.
CONCLUSIONS: A modified tracheal tube could be selected to ensure a patent airway and adequate ventilation in patients with bronchial rupture.

Tracheostomy is a common procedure seen in critically ill patients that require long term ventilatory support. As with all airway access procedures, tracheotomy with prolonged tracheal tube placement comes with possible risks such as tracheal scarring, tracheal rupture, pneumothorax, tracheoesophageal fistula among others. Another possible complication, though rare, is escape of free air into the surrounding tissue, as well as pneumomediastinum (PM). This may occur due to various reasons, some of them being tracheal rupture, barotrauma or tracheal tube mispositioning. Pneumomediastinum may present with concurrent free air in other body cavities such as the peritoneum, thorax or subcutaneous tissue. Though often not life-threatening it may require treatment including high flow oxygen, ventilator management or occasionally, surgical intervention. Herein we describe a rare case of PM with communicating pneumoperitoneum and massive subcutaneous emphysema due to tracheal tube mispositioning along with a review of the literature.