Abstract Introduction Tracheal rupture is a rare but potentially life-threatening complication of endotracheal intubation, often associated with emergency airways, multiple attempts, or excessive cuff pressure. Advanced age and airway fragility increase the risk. Clinical suspicion should be raised in patients with subcutaneous emphysema, pneumomediastinum, or unexplained ventilatory difficulty. Early recognition with imaging and bronchoscopic confirmation is critical, and management may be surgical or conservative, depending on stability and extent of injury. Case Report An 84-year-old woman with asthma presented with acute metabolic encephalopathy, hypoxia, hypertension, and tachycardia, with a GCS of 3. Emergent intubation required multiple attempts: video laryngoscopy failed to advance the endotracheal tube; direct laryngoscopy with a smaller tube was successful, without the use of a bougie or rigid stylet. Chest X-ray showed right mainstem intubation and right middle lobe consolidation. She tested positive for COVID-19, RSV, and Influenza A. After tube repositioning, oxygenation improved. She developed sepsis with hypoxic hypercapnic respiratory failure requiring vasopressors and antibiotics. On ICU day 1, subcutaneous emphysema, pneumomediastinum, and suspected tracheal injury were noted. CT confirmed a posterior wall defect near the carina and a moderate left pneumothorax. Bronchoscopy visualized a mucosal flap. On ICU day 3, she deteriorated with tension pneumothorax and profound acidosis (pH 6.98), requiring chest tube, sedation, and paralysis. Transfer to a tertiary center was delayed. On ICU day 21, tracheostomy was performed. A 35 mm posterior tracheal tear was confirmed, and she was managed conservatively with gradual improvement and discharge to rehabilitation. Discussion Tracheal rupture should be suspected in patients with post-intubation subcutaneous emphysema or ventilatory instability, particularly in the elderly or those with underlying airway disease. CT and bronchoscopy remain diagnostic cornerstones. While surgical repair is indicated for large or unstable tears, conservative management can be successful in stable patients under close multidisciplinary monitoring. This case underscores the importance of early recognition, imaging, and individualized treatment strategies in managing complex airway injuries. Conclusion Difficult intubation in elderly patients can result in tracheal rupture, a rare but severe complication. Prompt identification through imaging and bronchoscopy, coupled with coordinated multidisciplinary care, is essential. Selected patients may achieve favorable outcomes with conservative management, highlighting the need for vigilance and tailored therapy in airway trauma. This abstract is funded by: None
Javed et al. (Fri,) studied this question.