Fatal tension pneumopericardium complicating tracheostomy

The findings in a patient who developed a fatal pneumopericardium following tracheostomy are reported. This complication of tracheostomy does not appear to have been reported previously in the literature.. When recognized, pneumopericardium is a treatable lesion, and clinicians should be aware of this potential complication.     

Emphysema and pneumothorax after percutaneous tracheostomy: case reports and an anatomic study

STUDY OBJECTIVE: Part 1: To describe cases of emphysema (subcutaneous and/or mediastinal) and pneumothorax after percutaneous dilational tracheostomy (PDT) in a series of 326 patients, and to review the existing literature describing the incidence and possible mechanisms. Part 2: To analyze the potential mechanisms for the development of emphysema and pneumothorax in human cadaver models. DESIGN: A retrospective analysis of PDTs, in combination with an anatomic study in human cadavers. MATERIALS AND METHODS: Part 1: All ICU patients who underwent PDT between 1997 and 2002 were enrolled in the study. We analyzed the cases of emphysema and pneumothorax. Similar cases were retrieved from the literature and underwent a systematic review. Part 2: The relevant anatomic structures were studied. We simulated the clinical situation after PDT in a human pathologic study in order to induce subcutaneous emphysema and pneumothorax. MEASUREMENTS AND RESULTS: Part 1: Five cases of subcutaneous emphysema (1.5%) and two cases of pneumothorax (0.6%) are described. In the literature search, we found 41 cases of emphysema (1.4%) and 25 cases of pneumothorax (0.8%) in a total of 3,012 patients. Part 2: Subcutaneous emphysema could easily be induced in a human cadaver model by inflating air in the pretracheal tissues and after posterior tracheal wall laceration. Air leakage was also possible through a fenestrated cannula via the space between the inner nonfenestrated cannula and outer cannula and then through the fenestration. CONCLUSIONS: We conclude that one mechanism for the development of emphysema is an imperfect positioning of the fenestrated cannula, whereby the fenestration is extraluminal. For this reason, fenestrated cannulas should not be used immediately after placement of a PDT. Posterior tracheal wall laceration is another mechanism responsible for emphysema after PDT. After perforation of the posterior tracheal wall, the pleural space can be reached easily. This may result in a pneumothorax.     

Rapid percutaneous tracheostomy

We describe a new method of performing percutaneous tracheostomy rapidly and safely using a specialized instrument kit. The technique permits the safe insertion of a full-sized 7.0 (ID) or 7.5 mm (ID) cuffed cannula into the trachea within 1-2 min, through the membranous second intercartilagenous space. Animal studies have demonstrated a superior healing process compared to that seen after conventional tracheostomy techniques.     

ST elevation and tension pneumothorax

We present a case of a sixty-nine-year-old male admitted to the hospital because of an acute respiratory failure that needed intubation and mechanical ventilation. Shortly after several attempts of right and left (the last one successful) subclavian vein cannulation (the last one successful) he developed a bilateral tension pneumothorax with important hemodynamic repercussion, a critical hypoxia and an ST elevation in inferior leads. Other more typical electrocardiographic changes could be observed: decrease in QRS amplitude and diminishing of precordial R voltage. After removing the air of the right pleural space, all the electrocardiographic signs disappeared returning to normal without electric or enzymatic assay of myocardial necrosis.     

Complications of percutaneous tracheostomy

Percutaneous tracheostomy is a technique that, reputedly, is simple to perform and causes few complications. It is routinely used in intensive care. We present two patients with tracheal stenosis. In one patient, we had to perform an anastomotic resection to cure the patient; in the other patient, we had to place an endoluminal conformer. To our knowledge, this complication has not been reported in association with the use of this technique.     

Subcutaneous emphysema and pneumothorax complicating diagnostic colonoscopy

A case of subcutaneous emphysema and pneumothorax secondary to a diagnostic colonoscopy is presented. While 11 cases of retroperitoneal emphysema due to colonoscopy were identified in the literature, there are only two further reports of pneumothorax. Possible etiologic and therapeutic aspects are discussed.     

Gastrothorax mimicking acute tension pneumothorax

We describe a case of respiratory failure due to an acute tension gastrothorax in an elderly patient, secondary to an episode of vomiting. Initially the scout view was interpreted as a tension pneumothorax. Eventually the computed tomography (CT) of the thorax revealed a transdiaphragmatical herniation of the stomach and other visceral organs. An endoscopic desufflation procedure was performed, leading to improvement of the vital signs. Consequently, surgical repair was performed. It is important to be aware of specific radiologic signs, suggesting that the intrathoracic air collection is not caused by a pneumothorax. The initial treatment of a tension gastrothorax is nasogastric or orogastric decompression.     

Spontaneous pneumothorax complicating rheumatoid lung disease

This case report describes the pleuro-pulmonary involvement in a young patient with rheumatoid arthritis (RA) of one and half year duration. The early involvement of lung interstitium in a 27-year-old male and development of pneumothorax were the unusual features. The various aspects of rheumatoid lung disease (RLD) and its clinical significance were briefly discussed.     

Mediastinitis after percutaneous dilatational tracheostomy

In our experience, PDT after total arch replacement, especially after dissection of neck vessels, should be approached with caution. A long skin incision that allows discharge to drain from the wound and a sufficiently long postoperative tracheostomy period to allow tissue healing in the neck are necessary for prevention of mediastinitis.     

Managing complications of percutaneous tracheostomy and gastrostomy

Percutaneous tracheostomy and gastrostomy are some of the most commonly performed procedures at bedside in the intensive care unit. While they are generally considered safe, they can be associated with numerous short and long-term complications, many of which can occur long after their placement and cause significant morbidity. Performers of these procedures should possess a comprehensive understanding of procedural indications and contraindications, and know how to recognize and manage complications that may arise. In this review, we highlight complications of percutaneous tracheostomy and describe strategies for their prevention and management, with a special focus on post-tracheostomy tracheal stenosis. Other complications reviewed include bleeding, pneumothorax and subcutaneous emphysema, posterior wall injury, tube displacement, tracheomalacia, tracheoinominate artery fistula, tracheo-esophageal fistula, and stomal cellulitis. Gastrostomy complications and their management are also discussed including bleeding, internal organ injury, necrotizing fasciitis, aspiration pneumonia, buried bumper syndrome, tumor seeding, wound infection, tube displacement, peristomal leakage, and gastric outlet obstruction. In light of the potentially serious outcomes associated with complications of percutaneous tracheostomy and gastrostomy, the emphasis should be placed on risk-reduction strategies to minimize morbidity and mortality. We therefore present detailed pragmatic and comprehensive checklists to serve as a reference for clinicians involved in performing these procedures.     

Case Report: Pneumomediastinum and pneumothorax complicating colonoscopy

Colonic perforation is potentially the most serious complication of colonoscopy. Both the clinical manifestation and rapidity of onset of symptoms can vary depending on whether the perforation occurs directly into the peritoneal cavity or into the retroperitoneal space. Colonic perforation is often associated with abdominal pain, although more uncommon presentations have been documented. A case report of a unilateral pneumothorax and pneumomediastinum complicating colonoscopy is described, which responded well to conservative measures without recourse to surgical intervention, antibiotic therapy or parenteral alimentation.     

Comparison of surgical and percutaneous dilational tracheostomy

When significant clinical end points are considered, PDT is a cost-effective and safe alternative to ST in critically ill patients in the ICU when performed by skilled and experienced practitioners [1, 40]. There are insufficient data to establish clear superiority of either technique. Important advantages of PDT may include eliminating the need for operating room facilities and personnel by the performance of the procedure at the bedside and significantly decreasing the time interval between the decision to perform tracheostomy and the actual procedure [1, 2, 20].     

Hydatid disease presenting as tension pneumothorax

The case of stockfarmer with hydatid disease which presented as a left tension pneumothorax is described. The diagnosis was not made until the patient underwent a thoracotomy for a complicating empyema.     

Giant bronchogenic cyst mimicking tension pneumothorax

An 18-month-old girl presented with high fever and vomiting. Pneumothorax and a cystic formation in the right hemithorax were found on a chest radiograph. The cyst measuring 10 x 10 x 8 cm was resected by a simple wedge resection. Histology revealed a complicated bronchogenic cyst with abscess formation.