Pneumomediastinum, subcutaneous emphysema and respiratory arrest after 'mediastinal intubation'.

摘要

A 69-year-old male with chronic obstructive pul-monary disease, needing mechanical ventilation via a percutaneous dilatational tracheotomy was transferred from a nursing home to our hospital emergency room. He had acute respiratory failure and massive subcutaneous emphysema of the chest. The tracheotomy tube had dislodged and could not be reinserted. On arrival, he was manually ventilated using a regular tracheal tube placed into the tracheostomy stoma by a paramedic. The patient had a low oxygen saturation, bradycardia, and hypotension. The patient's trachea was orally intu-bated. The orotracheal tube cuff was placed below the tracheotomy. High inspiratory airway pressures (30 mm Hg) were initially needed during ventilation to achieve an acceptable tidal volume and oxygen saturation (>90%). Chest-CT (Figure 1} showed that the tracheal tube inserted via the tracheostomy stoma was in the mediastinum ("mediastinal intubation"; arrow Figure 1). Chest-CT showed air in the mediastinum (pneumomediastinum) and the subcutaneous tissues, but no pneumothoraces.