Although percutaneous dilatational
tracheostomy (
PDT) has become a safe procedure for
airway management in
critically ill patients, this operation can be associated with serious life-threatening complications. Massive
subcutaneous emphysema is an unusual and sometimes lethal complication which may extend the
length of stay in the intensive care unit (ICU). We report 2 cases, including 1 fatality, of massive
subcutaneous emphysema without tracheal wall
laceration that occurred in the ICU after elective bronchoscopy-guided Ciaglia Blue Rhino (Cook
Critical Care, Bloomington, IL, USA)
PDT. Our analysis of these cases suggested that
PDT-related
barotraumas and imperfect positioning of the fenestrated
tracheostomy tube could be the possible mechanisms for the observed complications. In case 1, we reduced the
ventilator pressure and prescribed
bronchodilator to decrease the airway pressure and keep the airway patent. In case 2, the suggested approach was to check if the fenestration of
tracheostomy tube was extraluminal or change to non-fenestrating cannulas. For diminishing the impact of
PDT on respiratory mechanics, especially in patients with underlying
lung diseases, we recommend introducing the
bronchoscope only when needed, instead of keeping the
bronchoscope in the airway throughout the
PDT procedure and using
forceps to create a larger stoma if the dilation procedure is not smooth.