BACKGROUND: Airway management in tracheostomized patients may become particularly challenging in the presence of recent stomas, local infection, single-lung ventilation, and restricted intraoperative airway access. False passage ventilation is an uncommon but potentially catastrophic complication requiring immediate recognition and rescue.

CASE REPORT: We report the case of a 63-year-old man with a recent surgical tracheostomy performed after emergent cricothyrotomy for upper airway obstruction secondary to cervical cellulitis with mediastinal extension. The patient underwent urgent thoracotomy for mediastinal debridement under general anesthesia with single-lung ventilation achieved using a bronchial blocker through the existing tracheostomy tube. During surgery in the lateral decubitus position, abrupt loss of capnography and inability to ventilate occurred. Bronchoscopic evaluation demonstrated tracheostomy tube malposition with false passage ventilation associated with peristomal tissue dehiscence and severe local infection. In this context, the combination of single-lung ventilation, lateral decubitus positioning, and limited access to the tracheostomy created a particularly challenging intraoperative airway rescue scenario. Given the need for immediate restoration of oxygenation, emergency orotracheal intubation using videolaryngoscopy was successfully performed without prior supination, allowing rapid recovery of ventilation and completion of the procedure.

CONCLUSIONS: This case highlights the diagnostic and rescue challenges posed by false passage ventilation during thoracic surgery in recently tracheostomized patients. It reinforces the importance of early recognition of airway loss and prioritization of oxygenation-restoring rescue strategies in similar high-risk intraoperative settings. This report also underscores the vulnerability of recently created and infected tracheostomies during complex thoracic procedures requiring single-lung ventilation.

Keywords: Tracheostomy, one-lung ventilation, Intraoperative Complications, Anesthesia, General