B103-21 Air in the Wrong Space: Pneumomediastinum Following Traumatic Intubation

Abstract Introduction Post-intubation tracheal injuries are rare and under-reported in the literature. Risk factors include advanced age, female sex, emergent or difficult intubation, and incorrect endotracheal tube (ET) size. It can present as subcutaneous emphysema, pneumomediastinum or pneumothorax. Radiographic imaging followed by bronchoscopy can help confirm the diagnosis. A case of a post-intubation tracheal injury is described here; it resulted in extensive subcutaneous emphysema and pneumomediastinum that was managed conservatively. Case Presentation An 84-year-old woman was brought to the emergency department after being found unresponsive. Her past medical history included heart failure with preserved ejection fraction, hypertension, sick sinus syndrome, and coronary artery disease. Vitals were notable for hypothermia (31 °C). She was intubated for airway protection. Pertinent laboratory findings included an elevated white cell count (11.8). CT chest revealed multifocal pneumonia and CT head was unremarkable. She received fluids, vasopressor support, transcutaneous warming, broad spectrum antibiotics for septic shock due to pneumonia. She was improving but self-extubated while on a spontaneous breathing trial, and was switched to non-invasive ventilation. She required re-intubation the next day for airway protection. Later that day, she was found to have diffuse neck swelling with crepitus. CT chest revealed suspected tracheal injury (blue arrow, figure 1) at the level of the ET tube cuff with an overinflated cuff, extensive pneumomediastinum and subcutaneous emphysema (green and red arrows, figure 1). Thoracic surgery and ENT recommended conservative management with low volume ventilation and placement of the ET tube cuff beyond the tracheal injury. She was transferred to a higher center with interventional pulmonology, where conservative management was continued. Fibrin sealant, packing and stenting were deferred due to the risk of further breakdown of the defect. Subcutaneous emphysema progressively decreased on examination and subsequent imaging. Bronchoscopy and esophagogastroduodenoscopy performed two weeks after the traumatic intubation showed no tracheal tears or tracheoesophageal fistulas. A repeat bronchoscopy after three weeks revealed tracheal stenosis and tracheostomy was performed. She passed away seven months later due to a cardiac arrest from a massive gastrointestinal bleed. Discussion This case highlights the identification and management of post-intubation tracheal injuries. It can present as subcutaneous emphysema or pneumomediastinum. Older patients with multiple comorbidities may not be optimal surgical candidates. Conservative measures include lung protective ventilation, appropriate positioning of the ET tube to bypass the tracheal injury, avoiding overinflation of the ET tube cuff, and monitoring with frequent imaging. Fibrin sealant, packing, and stenting are additional options. This abstract is funded by: None