Head and neck trauma can result in difficult airway management. A 25-year-old male required emergency tracheal intubation on arrival to the emergency department following a motorbike accident. Despite the presence of a normal capnography a computed tomography scan demonstrated a tracheal opening, an extra-tracheal position of the distal end of the tracheal tube, and extensive subcutaneous emphysema. The tube was re-directed into the trachea and the tracheal injury was surgically repaired. This case highlights that the presence of a normal capnograph does not necessarily mean that the distal end of the tracheal tube resides within the airway.

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UNASSIGNED: Tracheal injury is a rare but potentially serious acute complication of endotracheal intubation. Very few cases of tracheal injury associated with coagulation abnormalities have been reported in the literature. We present a rare case of a patient presenting with tracheal injury in combination with coagulation abnormalities following thyroidectomy.
UNASSIGNED: A 58-year-old woman with a history of postoperative chemotherapy for breast cancer, gastric polyps, multiple colonic polyps, esophageal papillary adenomas, and thyroid adenomas presented with dyspnea following 10 ml hemoptysis on the third day after thyroidectomy; she was admitted to the intensive care unit and underwent tracheal intubation for maintaining the airway. Subsequent bronchoscopy revealed a nodular red neoplasm 5-cm from the carina in the trachea obstructing part of the lumen, with a small amount of fresh hemorrhage on the surface. Tracheal injury was considered the preliminary diagnosis. Fiberoptic bronchoscope guided tracheal intubation helped prevent rupture of the tumor, and the cannula was properly inflated to arrest the bleeding while blocking the lower part of the trachea. An emergency surgical evacuation of the cervical hematoma was performed for managing postoperative bleeding. The patient demonstrated persistent pancytopenia despite frequent transfusions. Laboratory examination results revealed abnormal coagulation parameters, anemia, and hepatic dysfunction. Following a multidisciplinary team discussion, pituitrin for hemostasis, tranexamic acid for strengthening hemostasis treatment, and nutritional support and anti-infection treatment were initiated. Endotracheal tube cuff inflation was performed to compress the bleeding site. Complete resolution of the subcutaneous hematoma was observed nine days after the tracheal injury; bronchoscopy revealed residual ecchymosis in the airway hematoma with no evidence of obstruction.
UNASSIGNED: Conservative management of tracheal injury limited to the mucosa or submucosa without significant amount of active bleeding using endotracheal intubation is considered a practical and effective approach. Successful management was ensured by appropriate clinical suspicion, early multidisciplinary team discussion, and prompt diagnosis and interventions.

SARS-CoV-2 infection-induced hyper-inflammation is a key pathogenic factor of COVID-19. Our research, along with others\', has demonstrated that mast cells (MCs) play a vital role in the initiation of hyper-inflammation caused by SARS-CoV-2. In previous study, we observed that SARS-CoV-2 infection induced the accumulation of MCs in the peri-bronchus and bronchioalveolar-duct junction in humanized mice. Additionally, we found that MC degranulation triggered by the spike protein resulted in inflammation in alveolar epithelial cells and capillary endothelial cells, leading to subsequent lung injury. The trachea and bronchus are the routes for SARS-CoV-2 transmission after virus inhalation, and inflammation in these regions could promote viral spread. MCs are widely distributed throughout the respiratory tract. Thus, in this study, we investigated the role of MCs and their degranulation in the development of inflammation in tracheal-bronchial epithelium. Histological analyses showed the accumulation and degranulation of MCs in the peri-trachea of humanized mice infected with SARS-CoV-2. MC degranulation caused lesions in trachea, and the formation of papillary hyperplasia was observed. Through transcriptome analysis in bronchial epithelial cells, we found that MC degranulation significantly altered multiple cellular signaling, particularly, leading to upregulated immune responses and inflammation. The administration of ebastine or loratadine effectively suppressed the induction of inflammatory factors in bronchial epithelial cells and alleviated tracheal injury in mice. Taken together, our findings confirm the essential role of MC degranulation in SARS-CoV-2-induced hyper-inflammation and the subsequent tissue lesions. Furthermore, our results support the use of ebastine or loratadine to inhibit SARS-CoV-2-triggered degranulation, thereby preventing tissue damage caused by hyper-inflammation.

BACKGROUND: Mediastinoscopic surgery for esophageal cancer facilitates early postoperative recovery. However, it can occasionally cause serious complications. Here, we present the case of a patient with a tracheal injury diagnosed by a sudden increase in end-tidal carbon dioxide (EtCO2) during mediastinoscopic subtotal esophagectomy.
METHODS: A 52-year-old man diagnosed with esophageal cancer was scheduled to undergo mediastinoscopic subtotal esophagectomy. During the mediastinoscopic procedure, the EtCO2 level suddenly increased above 200 mmHg, and the blood pressure dropped below 80 mmHg. We immediately asked the operator to stop insufflation and found a tracheal injury on the right side of the trachea near the carina by bronchoscopy. The endotracheal tube was replaced with a double-lumen tube, and the trachea was repaired via right thoracotomy. There were no further intraoperative complications. After surgery, the patient was extubated and admitted to the intensive care unit.
CONCLUSIONS: Monitoring EtCO2 levels and close communication with the operator is important for safely managing sudden tracheal injury during mediastinoscopic esophagectomy.

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BACKGROUND: Tracheal laceration is very rare but can be life-threatening if proper treatment is not provided. The general concept for the management of tracheal laceration is surgical repair through cervical incision or via thoracotomy. However, in the case of tracheal laceration after tracheostomy, tracheostoma could be extended to avoid urgent surgical repair and additional incision.
METHODS: A 30-year-old Asian woman suffered intracerebral hemorrhage. Tracheostomy was necessary for prolonged ventilator care. While tracheostomy was performed, the posterior tracheal wall was torn. After observing that, we reinserted endotracheal tube through the oral orifice. Following bronchoscopy showed torn posterior tracheal wall. The tearing wound was 5-6 cm in length, from the middle to distal parts of the trachea. We used minimally invasive procedure for extending the already existing tracheostoma.
CONCLUSIONS: In the case of tracheal laceration related to tracheostomy, a new incision is not necessary because the tracheal opening already exists. Using the extended tracheostomy technique, tracheal laceration can be repaired by endotracheal suture method.

BACKGROUND: Iatrogenic tracheal injury is a rare but potentially morbid condition and often poses a diagnostic challenge due to its rarity and the lack of specific clinical findings. Because a delayed diagnosis is associated with a higher mortality, a prompt diagnosis is essential. We report a case of an iatrogenic tracheal injury detected by subpleural emphysema as a rare initial manifestation.
METHODS: A 75-year-old woman was diagnosed with stage IA2 right lung cancer. During the surgery, visceral subpleural emphysema developed along the lung surface up to the interlobar fissure followed by subcutaneous emphysema in the anterior neck. Suspecting a tracheal injury, we aborted the surgery. Fiberoptic bronchoscopy revealed a longitudinal laceration on the membranous part of the distal trachea without esophageal involvement, consistent with a level II injury. Conservative management was chosen and she had a successful recovery.
CONCLUSIONS: Iatrogenic tracheal injury could initially manifest as visceral subpleural emphysema. Once subpleural emphysema is observed during surgery, a prompt diagnostic workup of the tracheal injury should be performed.

Tracheobronchial injury (TBI) associated with penetrating injuries has various clinical symptoms and often requires urgent surgical repair. A tracheal tube and/or placement of a drainage tube combined with multidetector computed tomography (CT) could be used to manage TBI without surgical repair in eligible patients. In this case report, we describe an 86-year-old woman with subcutaneous emphysema and suspected TBI caused by three knife wounds in her neck. After tracheal intubation at a local hospital, she was transferred to our hospital. On admission, she was diagnosed with subcutaneous and mediastinal emphysema due to TBI, as well as bilateral pneumothorax. We adjusted the position of the tracheal tube to a distal location from the TBI, and placed bilateral thoracic drainage tubes by referring to the CT images taken on admission and during the follow-up. The follow-up CT images revealed healing of the TBI. She did not show any worsening of her symptoms and she was successfully extubated on day 10 of her hospital stay. On day 18, she was considered self-reliant and was transferred to her previous hospital. Based on our experience in this case, we believe that ventilation with appropriate sedation, placement of a tracheal tube, and drainage are important conservative therapies for TBI caused by penetrating injuries. CT is also useful for evaluating the status of TBI.

Laryngeal and tracheal injuries are known complications of endotracheal intubation. Endotracheal tubes (ETTs) with subglottic suction devices (SSDs) are commonly used in the critical care setting. There is concern that herniation of tissue into the suction port of these devices may lead to tracheal injury resulting in serious clinical consequences such as tracheal stenosis. We aimed to describe the type and location of tracheal injuries seen in intubated critically ill patients and assess injuries at the suction port as well as in-hospital complications associated with those injuries.
We conducted a prospective observational study of 57 critically ill patients admitted to a level 3 intensive care unit who were endotracheally intubated and underwent percutaneous tracheostomy. Investigators performed bronchoscopy and photographic evaluation of the airway during the percutaneous tracheostomy procedure to evaluate tracheal and laryngeal injury.
Forty-one (72%) patients intubated with ETT with SSD and sixteen (28%) patients with standard ETT were included in the study. Forty-seven (83%) patients had a documented airway injury ranging from hyperemia to deep ulceration of the mucosa. A common tracheal injury was at the site of the tracheal cuff. Injury at the site of the subglottic suction device was seen in 5/41 (12%) patients. There were no in-hospital complications.
Airway injury was common in critically ill patients following endotracheal intubation, and tracheal injury commonly occurred at the site of the endotracheal cuff. Injury occurred at the site of the subglottic suction port in some patients although the clinical consequences of these injuries remain unclear.
RéSUMé: OBJECTIF: Les lésions laryngées et trachéales sont des complications connues de l’intubation endotrachéale. Les sondes endotrachéales (SET) avec dispositifs d’aspiration sous-glottiques (DASG) sont couramment utilisées aux soins intensifs. On craint qu’une hernie tissulaire dans l’orifice d’aspiration de ces dispositifs n’entraîne des lésions trachéales, résultant en de graves conséquences cliniques telles qu’une sténose trachéale. Nous avons cherché à décrire le type et l’emplacement des lésions trachéales observées chez les patients gravement malades intubés et à évaluer les lésions au port d’aspiration ainsi que les complications hospitalières associées à ces lésions. MéTHODE: Nous avons mené une étude observationnelle prospective auprès de 57 patients gravement malades admis dans une unité de soins intensifs de niveau 3 qui ont été intubés par voie endotrachéale et ont subi une trachéostomie percutanée. Les chercheurs ont réalisé une bronchoscopie et une évaluation photographique des voies aériennes au cours de la trachéostomie percutanée afin d’évaluer les lésions trachéales et laryngées. RéSULTATS: Quarante et un (72 %) intubés par SET avec DASG et seize (28 %) patients avec SET standard ont été inclus dans l’étude. Quarante-sept (83 %) patients ont présenté une lésion documentée des voies aériennes allant de l’hyperémie à l’ulcération profonde de la muqueuse. Une lésion trachéale commune était localisée sur le site du ballonnet trachéal. Une lésion au site du dispositif d’aspiration sous-glottique a été observée chez 5/41 (12 %) patients. Il n’y a pas eu de complications à l’hôpital. CONCLUSION: Les lésions des voies aériennes étaient fréquentes chez les patients gravement malades après une intubation endotrachéale, et les lésions trachéales se produisaient généralement au site du ballonnet endotrachéal. Des lésions se sont produites au site de l’orifice d’aspiration sous-glottique chez certains patients, bien que les conséquences cliniques de ces lésions restent incertaines.