Bilateral pneumothorax after emergency tracheotomy: two case reports and a review of the literature

Pneumomediastinum and pneumothorax during emergency tracheotomy under spontaneous ventilation: Macklin meets Müeller?

Potentially serious complications associated to emergency tracheotomy continue being a matter of concern. We review the pathogenesis of gas leakage in this setting and discuss about the possible mechanisms involved in its cause. We present two cases of pneumomediastinum, subcutaneous emphysema and pneumothorax in the context of emergency tracheotomy under spontaneous ventilation, finally resolved by chest drainage. The combination of overly negative pleural pressures due to extreme inspiratory efforts in the context of an almost completely obstructed airway together with over-pressurized alveoli because of gaseous entrapment secondary to serious expiratory obstruction appears to be the most plausible primary cause of air leaks in our patients. Understanding the underlying mechanisms evolved in its production will help clinicians to suspect and diagnose this phenomenon.

Bilateral pneumothoraces and pulmonary oedema following tracheostomy induced by acute tracheal obstruction

We describe the presentation of bilateral pneumothoraces with pulmonary oedema following an elective tracheostomy. A 69-year-old man underwent panendoscopy following primary chemoradiotherapy for locally invasive vocal cord carcinoma. A tracheostomy was performed for upper airway oedema and necrosis. Postoperatively, acute airway obstruction with profound desaturation developed. Tracheostomy tube suctioning dislodged an airway clot with clinical improvement and restoration of bilateral breath sounds. A chest X-ray subsequently demonstrated bilateral pneumothoraces with marked pulmonary oedema. Management, including chest drain insertion, resulted in stabilisation and subsequent full recovery. This case highlights the potential for more than one cause of life-threatening complication following tracheostomy. The importance of considering multiple pathologies in the setting of severe hypoxia and to institute prompt management is emphasised.