Abstract Introduction Tracheal injury following intubation is a rare but potentially life-threatening complication. Computed tomography (CT) is commonly used to evaluate suspected tracheal injury, with pneumomediastinum often considered a key finding. We present two cases demonstrating critical discordance between CT findings and bronchoscopic examination, highlighting that imaging alone is insufficient for diagnosis and management decisions. Case 1 A 75-year-old woman was admitted with interstitial pneumonia and respiratory failure. After development of voice changes and minimal subcutaneous emphysema, CT imaging revealed a suspected posterior tracheal wall injury with pneumomediastinum (Figure 1A). Diagnostic bronchoscopy ruled out significant tracheal injury (Figure 1C), allowing safe intubation for progressive respiratory failure. Bronchoalveolar lavage isolated Streptococcus pneumoniae. The patient was successfully managed conservatively with mechanical ventilation and antibiotic therapy. Case 2 A 78-year-old woman underwent elective thoracoscopic mitral valve replacement. During post-operative ICU stay, a severe hemoptysis was observed. CT scan demonstrated a suspected tracheal lesion without pneumomediastinum (Figure 1B). Bronchoscopy revealed a 10 cm longitudinal laceration of the posterior membranous tracheal wall with full-thickness injury proximally and esophageal exposure (Figure 1D). The patient underwent urgent primary surgical repair. The patient achieved full recovery without complications. Discussion These cases demonstrate critical limitations of CT imaging in evaluating suspected tracheal injury. In Case 1, pneumomediastinum with suspected tracheal injury on CT was proven false by bronchoscopy, with findings consistent with necrotizing pneumococcal pneumonia rather than iatrogenic injury. Conversely, Case 2 presented a severe 10 cm full-thickness tracheal laceration with esophageal exposure and no pneumomediastinum on imaging. This discordance challenges the assumption that pneumomediastinum reliably indicates or correlates with tracheal injury severity. CT imaging demonstrated poor positive and negative predictive value for actual bronchoscopic findings. The presence of pneumomediastinum may reflect alternative pathology such as alveolar rupture from severe pneumonia, while its absence does not exclude significant tracheal injury, even with esophageal communication.These cases emphasize that CT findings may not reliably predict bronchoscopic findings in suspected tracheal injury. Direct bronchoscopic visualization is mandatory when tracheal injury is suspected, regardless of CT appearance. This approach prevented unnecessary intervention in Case 1 while enabling life-saving surgical repair in Case 2. Clinicians should maintain a low threshold for bronchoscopy in any patient with clinical suspicion of tracheal injury. This abstract is funded by: None
Uccelli et al. (Fri,) studied this question.