BACKGROUND
Tracheostomy is a cornerstone of long-term intensive care, utilized in approximately 15% of intensive care unit patients. While beneficial, prolonged tracheostomy intubation initiates structural changes within the tracheal architecture, predisposing patients to severe late-stage complications, including secondary pneumomediastinum, which can rapidly progress to tension physiology and obstructive shock. Specific triggers, pathophysiological pathways (eg Macklin effect vs direct disruption), and multi-compartment air tracking in tracheostomized populations remains incompletely understood. This report seeks to guide early prevention and emergency management by describing chronological clinical presentations, diagnostic decision-making, and therapeutic outcomes of complications in 3 prolonged-tracheostomy patients.
CASE REPORT
Three male patients underwent prolonged tracheostomy intubation (>1 month) and developed pneumomediastinum following airway manipulation. A 38-year-old patient developed severe subcutaneous emphysema (SE) 48 hours post-decannulation following tracheal polypectomy. Computed tomography (CT) ruled out tension pneumothorax, and stable hemodynamics justified successful conservative management. A 69-year-old patient experienced sudden dyspnea and SE during bedside bronchoscopy. CT revealed extensive soft-tissue gas and left-sided pneumothorax, requiring an emergency bedside subcutaneous incision and closed chest drainage due to rapid respiratory deterioration. A 19-year-old patient developed rapidly spreading SE and progressed to cardiac arrest during a bronchoscopic polypectomy. Malignant tension pneumomediastinum ensued following massive gas entry, severely obstructing venous return, which proved fatal despite advanced life support.
CONCLUSIONS
Secondary pneumomediastinum during airway manipulation demands a high index of clinical suspicion. While stable cases resolve conservatively, rapid gas accumulation causes obstructive shock requiring immediate thoracic decompression. Strict preoperative cough suppression and continuous cuff pressure monitoring are critical preventative strategies.

Keywords: Intubation; Pneumomediastinum; Pulmonology; Tracheostomy; Bronchoscopy; Subcutaneous Emphysema; Case Reports