Pneumomediastinum and pneumoperitoneum caused by tracheostomy displacement.

To cite: Kniese CM, Jan MY, Diab K. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015211238 DESCRIPTION A 20-year-old woman with a history of morbid obesity secondary to Prader-Willi syndrome and recent acute-on-chronic respiratory failure requiring tracheostomy placement presented to the emergency department of a regional hospital with respiratory distress and concern for tracheostomy obstruction. Her tracheostomy was exchanged, and mechanical ventilation was initiated prior to transfer to our hospital. She continued to experience respiratory distress; plain chest radiography demonstrated pneumomediastinum (figure 1A). Dedicated CT of the chest and abdomen demonstrated a left-sided pneumothorax, pneumomediastinum and pneumoperitoneum, which appeared to track down from the thoracic cavity (figure 1B–D). At the time, the patient was in acute kidney failure and urine output was decreased. Bladder pressure was measured at 23 cm H2O. Her constellation of findings was believed to be secondary to creation of a false tract during tracheostomy exchange. Otolaryngology was consulted; a guided tracheostomy replacement with a 6.0 Shiley cuffed tracheostomy tube was performed. A left-sided 20 Fr thoracostomy tube was placed with lung reexpansion confirmed on repeat imaging (figure 1E). Bladder pressure decreased to 14 cm H2O the next day, and urine output improved. The patient’s chest tube was removed on day 7, and she required