Journal of Postgraduate Medicine
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Year : 2003  |  Volume : 49  |  Issue : 2  |  Page : 188-9  

Endotracheal intubation related massive subcutaneous emphysema and tension pneumomediastinum resulting in cardiac arrest.

M Pandey, A Jain, A Mehta, M Sharma 

Correspondence Address:
M Pandey

How to cite this article:
Pandey M, Jain A, Mehta A, Sharma M. Endotracheal intubation related massive subcutaneous emphysema and tension pneumomediastinum resulting in cardiac arrest. J Postgrad Med 2003;49:188-9

How to cite this URL:
Pandey M, Jain A, Mehta A, Sharma M. Endotracheal intubation related massive subcutaneous emphysema and tension pneumomediastinum resulting in cardiac arrest. J Postgrad Med [serial online] 2003 [cited 2022 Sep 27 ];49:188-9
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Tracheal injuries account for 15% of all airway injuries and in majority of the cases involve routine tracheal intubation and appropriate anaesthesia care.[1] The authors would like to describe a patient who developed subcutaneous emphysema and tension pneumomediastinum related to multiple intubation attempts resulting in cardiac arrest.

A 42-year-old man underwent left hemimandiblectomy and radical neck dissection. Difficult intubation was anticipated as the mouth opening was 2 fingers, Mallampati grade II airway and tumour was bulging inside the oral cavity. After confirming adequacy of bag mask ventilation, muscle relaxant was given. Laryngoscopy revealed a Cormack and Lehane grade 3 glottic view and orotracheal intubation was achieved at the second attempt after using a stylet and applying external laryngeal pressure and a gentle pull on the angle of the mouth. The surgery later necessitated a change to nasal tube which required two more attempts. No air leak or loss of ventilation was observed during the IPPV. The subsequent course of anaesthesia and surgery was uneventful.

The patient was shifted to ICU for elective ventilation in view of the surgical oedema. He developed bouts of coughing on the tube when a T piece weaning trial was given with a partially deflated cuff next morning. Within 10 minutes, the oxygen saturation decreased to 80% and a swelling with palpable crepitus appeared over the face, neck, chest and upper extremities. The patient became cyanosed and developed cardiac arrest, which was treated, and a normal sinus rhythm was restored.

An x- ray chest revealed the presence of air in the subcutaneous tissue planes of the neck and axilla with a pneumomediastinum. A surgical tracheostomy was done to decompress the mediastinum and resulted in significant haemodynamic improvement. A subsequent fibreoptic bronchoscopy revealed a 2 cm red streak beyond the larynx, but the area beyond the tracheostomy was normal. CT scan of the head - neck showed air pockets in the pyriform fossa but the pneumomediastinum had disappeared. The patient was treated conservatively and discharged from the hospital after 20 days.

Acute subcutaneous emphysema and pneumomediastinum are rare complications related to endotracheal intubation,[2] and are potentially fatal if left untreated. Poor visualisation of the larynx, repeated attempts at blind advancement of endotracheal tube and use of stylets are significant risk factors for intubation related airway trauma.[3] We feel that repeated intubation attempts may have created a raw area on the posterior tracheal wall and straining on the tube during weaning may have resulted in a high intrathoracic pressure and disruption of the injured site. Subsequent high negative intrathoracic pressure generated might have entrained air along the sides of the tube through the tracheal rent into the subcutaneous tissue causing subcutaneous emphysema and tension pneumomediastinum.

The development of cardiac arrest and improvement following tracheostomy confirm our diagnosis of tension pneumomediastinum. Tracheostomy allows for mediastinal decompression by providing a route for accumulated gases to escape to the atmosphere and thus hasten the process of resolution.[4] A planned fibreoptic bronchoscopy guided nasotracheal intubation might have avoided significant morbidity in this patient.


1Domino KB, Posner KL, Caplan RA, Cheney FW. Airway injury during anaesthesia: a closed claim analysis. Anesthesiology 1999;91:1703-11.
2Tan CS, Tashkin DP, Sassoon H. Pneumothorax and subcutaneous emphysema complicating endotracheal intubation. South Med J 1984;77:253-5.
3King K, Mandava B, Kamen JM. Tracheal tube cuffs & tracheal dilation. Chest 1975;67:458-62.
4Conetta R, Barman AA, Iakovou C, Masakayan RJ. Acute ventilatory failure from massive subcutaneous emphysema. Chest 1993;104:978-80.

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