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Clinical Images

The Perplexity of Air

Shirin Karimi

November 16, 2019

A 70 year old male with COPD, CAD, HFpEF, and atrial fibrillation on Coumadin was initially admitted to the ICU for lower extremity cellulitis and COPD exacerbation. Hospital course was complicated by acute hypoxic respiratory failure requiring intubation. Post intubation chest x-ray showed a large right sided tension pneumothorax likely secondary to COPD bleb rupture.  The patient underwent subsequent placement of a large bore chest tube. Two days after intubation, the patient was noted to have increased distension of the abdomen and scrotum with worsening subcutaneous emphysema. CT chest showed marked subcutaneous, intramuscular, mediastinal, and pericardial emphysema. CT abdomen/pelvis showed extensive subcutaneous emphysema from the neck to the upper thigh and extensive intramuscular edema in the anterior abdominal wall.  Bronchoscopy revealed a posterior membrane laceration 1-2 cm proximal to the carina, likely from traumatic endotracheal intubation (Figure 1).  EGD did not show evidence of esophageal injury. The patient was transferred to a tertiary care facility for emergent tracheal repair. The patient underwent right thoracotomy, primary suture repair of the tracheal laceration with intercostal muscle flap buttress.  Postoperatively, the patient required a tracheostomy and PEG tube placement for failure to be weaned from the ventilator. 

Figure 1: Tracheal rupture visualized on bronchoscopy (tear indicated by arrow)


1.  Which of the following ventilator changes can be seen in tracheal rupture? 

A: Increase in tidal volume

B: Decrease in respiratory rate

C: Decrease in tidal volume

D: Decrease in minute ventilation 

2.  What is the classic physical finding of a patient status post tracheal rupture? 

A: Egophany

B: Coarse crackles

C: Vesicular breath sounds

D: Subcutaneous emphysema


1.  C. Decrease in tidal volume

2.  D. Subcutaneous Emphysema


Tracheal rupture after endotracheal intubation is a rare and often under recognized complication seen in both uncomplicated intubations and emergent intubations. The rupture can be attributed to multiple vigorous attempts at intubation, perforation of the mucosa from the stylet protruding from the tracheal tube, over-inflation or rapid inflation of the tracheal/bronchial cuff, malpositioning of the tube, or vigorous coughing during intubation. Evidence of tracheal rupture is seen very soon after initial intubation with the classic development of subcutaneous emphysema and respiratory distress. Ventilator changes include a decrease in tidal volume. Radiologic findings with computed tomography include pneumomediastinum, subcutaneous emphysema, and pneumothorax, but diagnosis is only confirmed by bronchoschopy1. Life threatening complications include tension pneumothorax, anoxia due to most of the tidal volume exiting through the tracheal tear, and mediastinitis. Once tracheal rupture is confirmed, patients should undergo surgical repair2.


  1. Marty-Ané, Charles-Henri, et al. "Membranous tracheal rupture after endotracheal intubation." The Annals of thoracic surgery 60.5 (1995): 1367-1371.

  2. Óvári, Attila, et al. "Conservative management of post-intubation tracheal tears—report of three cases." Journal of thoracic disease 6.6 (2014): E85.

Author (at time of submission):

Shirin Karimi, M.D. is a PGY2 in internal medicine at Cambridge Health Alliance. She received her medical degree at the University of Connecticut School of Medicine. She studied Literature at American University and has published extensively on the medical humanities in Connecticut Medicine and Academic Medicine. She is also the author of a book of poetry entitled "Enclosures: Reflections from the Prison Cell and the Hospital Bed".