Management of Massive Post-Tracheostomy Subcutaneous Emphysema with an Adjustable-Length, Wire-Reinforced Tracheostomy Tube: A Case Report and Review of literatureAbstract: Massive subcutaneous emphysema with pneumomediastinum is a rare but potentially life-threatening complication following tracheostomy, for which standardized management strategies are lacking. We report the case of a 67-year-old man who developed progressive cervicofacial and thoracic subcutaneous emphysema several days after an otherwise uncomplicated surgical tracheostomy using a fenestrated tube. Diagnostic evaluation with fiberoptic tracheoscopy and computed tomography of the neck and chest demonstrated extensive subcutaneous emphysema, pneumomediastinum, tracheal dilation, and a suspected persistent air leak related to tube–trachea size mismatch and the presence of fenestrations. Initial conservative bedside measures failed to halt progression. Subsequent exchange to a non-fenestrated, flexible, wire-reinforced cuffed tracheostomy tube with adjustable length resulted in rapid regression and complete resolution of the emphysema without the need for further intervention. This case highlights the importance of early recognition of anatomical and device-related contributors to post-tracheostomy air leak and demonstrates that prompt, targeted tracheostomy tube selection can provide effective airway sealing and obviate invasive management strategies.Keywords: Tracheostomy; Subcutaneous emphysema; Pneumomediastinum; Tracheomegaly; Adjustable-length tracheostomy tubeKey Clinical Message: Massive post-tracheostomy subcutaneous emphysema may result from tracheal–tube size mismatch and fenestrations, particularly in the presence of tracheomegaly. When conservative measures fail, early exchange to a non-fenestrated, adjustable-length, wire-reinforced cuffed tracheostomy tube restores airway sealing and resolves emphysema, avoiding invasive decompressive procedures.Introduction: Tracheostomy is a surgical airway procedure that involves creating an opening in the anterior tracheal wall to secure ventilation and airway access. It is commonly performed in patients with acute respiratory failure following prolonged endotracheal intubation, upper airway obstruction, anticipated difficult airway, or inability to manage copious secretions 1. Early perioperative complications include hemorrhage, pneumothorax or pneumomediastinum secondary to false tract formation, subcutaneous emphysema, esophageal injury, and tracheal ring fracture. Late complications are typically associated with long-term tracheostomy use and include airway stenosis, granulation tissue formation, tracheomalacia, and the development of tracheoesophageal or tracheoinnominate fistulas2.Subcutaneous emphysema (SE) represents an uncommon complication of tracheostomy, with reported incidence rates of up to 9%3. SE refers to the abnormal accumulation of air within the subcutaneous tissues. Its pathophysiology follows one of two mechanisms: endogenous gas production, as seen in necrotizing infections, or air dissection into tissue planes from internal or external sources of pressurized air 4. The latter is more frequently encountered and is associated with conditions such as pneumothorax, pneumomediastinum, and laryngotracheal injury.Only a limited number of reports describe massive subcutaneous emphysema with concomitant pneumomediastinum following tracheostomy, yet a standardized management approach has not been established. In this report, we describe a patient who developed massive SE of the head and neck with pneumomediastinum several days after a conventional fenestrated tracheostomy tube insertion. To our knowledge, this is the first reported case in which massive post-tracheostomy subcutaneous emphysema associated with tracheomegaly was successfully managed primarily through targeted tracheostomy tube redesign using an adjustable-length, wire-reinforced system, without invasive decompressive measures.Written informed consent was obtained from the patient for publication of this case report and any accompanying images.Case Presentation: A 67-year-old man with idiopathic pulmonary fibrosis (IPF), hypertension, prior nasal basal cell carcinoma excision, depression on medical therapy, significant coronary artery calcifications, and a recent admission for medically treated pneumonia re-presented with hypoxemia and increased work of breathing.He was diagnosed with hospital-acquired pneumonia due to methicillin-sensitive Staphylococcus aureus , complicated by acute type II respiratory failure requiring intensive care unit admission and continuous BiPAP. After multiple failed weaning attempts, even for minimal amount of time, our team was consulted for tracheostomy placement.The patient underwent an uncomplicated surgical tracheostomy. A size 8 fenestrated tracheostomy tube was placed between the first and second tracheal rings using a Björk flap technique. The postoperative course was initially unremarkable, and skin sutures were removed on postoperative day 7 (POD-7) per institutional protocol.On POD-9, our team was re-consulted for progressive subcutaneous emphysema. The patient was awake, hemodynamically stable, and without respiratory distress. Ventilator requirements were minimal (PEEP 5 cm H₂O, FiO₂ 40%), with adequate tidal volumes and minimal air leak. Examination revealed extensive subcutaneous emphysema with palpable crepitus involving the neck bilaterally, extending to the cheeks and lower eyelids. The tracheostomy stoma was well healed without dehiscence; however, the tube was excessively mobile, with the fenestra abutting the superior edge of the stoma. Figure 1aFlexible fiberoptic tracheoscopy through the tracheostomy tube demonstrated a patent airway with clear visualization of the carina and no evidence of intraluminal obstruction, tracheomalacia, or tracheal injury. Chest radiography revealed no pneumothorax. Initial management included cuff optimization, improvement of tracheostomy positioning, and close observation. Despite these measures, subcutaneous emphysema progressed over the following two days, extending to the parietal scalp, while the patient remained clinically stable.Given the SE progression, computed tomography (CT) of the neck and chest was obtained, demonstrating diffuse subcutaneous emphysema involving the chest wall, mediastinum, superficial and deep cervical spaces, retropharyngeal and prevertebral spaces, with extension to the orbits and temporal regions Figure 1b, c. The tracheostomy tube tip was positioned 5–6 cm above the carina, with an enlarged tracheal diameter (26mm – 40 mm) likely related to tractional airway remodeling in the setting of advanced fibrotic lung disease. Figure 2a, b. The fenestrae were predominantly intraluminal, with partial abutment against the anterior tracheal wall and adjacent soft tissues Figure 3a,b. No discrete tracheal defect or sinus pathology was identified.Based on these findings, supplemental oxygen was increased to approximately 60% FiO₂ overnight to promote nitrogen washout and facilitate resorption of subcutaneous air; however, no clinical improvement was observed. In the setting of extensive subcutaneous emphysema, a relatively large tracheal diameter, the presence of fenestrations, and failure of supportive measures, tracheostomy tube exchange was planned. On POD-15, 2025, the patient was taken to the operating room, where inspection of the stoma revealed a localized breach of the subcutaneous tissues at the superior aspect of the wound flange, without evidence of tracheal wall injury. The fenestrated tube was replaced with a size 9, non-fenestrated, flexible wire-reinforced cuffed tracheostomy tube from a different manufacturer. Table 1. The cuff was inflated to 25 cm H2O, measured with a manometer, and the tracheostomy ties were readjusted to improve stabilization. The tube length was adjusted to 95 mm until no air leak was observed. Subcutaneous emphysema began to regress within three days and resolved completely without further intervention. Figure 4Discussion: SE is a rare complication of tracheostomy, typically occurring within hours to days following the procedure. Predisposing factors include extensive tissue dissection, tracheostomy tube obstruction, high-pressure mechanical ventilation 5, use of fenestrated tracheostomy tubes 6, and percutaneous tracheostomy techniques 7. Following tracheostomy, SE most commonly results from air leakage due to cannula malposition or displacement. In most cases, SE is managed conservatively, as it is generally benign and self-limiting with spontaneous air resorption. However, when SE is extensive or associated with pneumomediastinum, it may progress to a life-threatening condition with acute cardiovascular compromise, necessitating prompt and more aggressive intervention8. The primary goal in managing SE is effective decompression of the thoracic inlet and cervical soft tissues through identification and correction of the source of air leakage, leading to gradual resolution of the emphysema 3. Several invasive strategies have been described for severe or refractory cases, including multiple subcutaneous “gill slit” incisions to relieve tension SE, as reported by Showmaker et al. 9, and negative-pressure wound therapy combined with surgical closure of tracheostoma dehiscence, as described by Kim et al.10.In contrast, conservative strategies have also been described. El Shoubi et al, reported clinical improvement following simple release of tracheostomy tie tension, thereby relieving external compression and facilitating air egress 11. El Kholy et al. managed their case with administration of 100% inspired oxygen for 48 hours, promoting nitrogen washout, increasing the diffusion gradient for gas resorption, and accelerating air absorption by approximately four- to six-fold 12.In our case, several anatomical and device-related factors likely contributed to the development of massive SE. The markedly enlarged tracheal diameter observed on imaging, likely related to the patient’s IPF, resulted in a size mismatch with the initially placed size 8 tracheostomy tube 13. In addition, the presence of fenestrations, despite use of a non-fenestrated inner cannula, likely facilitated air leakage 14,15. Escaping air passed through a partial dehiscence at the superior aspect of the stoma and dissected superiorly along cervical soft tissue planes, leading to progressive SE. In the most closely reported case by Mostert et al., SE developed acutely within minutes following percutaneous tracheostomy and was managed by replacing a fenestrated tracheostomy tube with a non-fenestrated tube of the same size 6. Table 2.Although the patient remained clinically stable, early intervention was pursued to prevent potential deterioration, with the primary objective of controlling the source of air leakage. The initial tracheostomy tube was a conventional fenestrated cuffed tube with a smaller inner diameter (7.6 mm) but a comparable outer diameter (12.2 mm) to the subsequently used extended, adjustable-length tube, which provided a larger inner diameter (9.0 mm). This highlights an important manufacturer-dependent consideration: a larger tracheostomy tube size does not necessarily correspond to a larger outer diameter, as inner and outer dimensions vary across designs. Thus, in patients with enlarged tracheas, airflow and sealing efficacy are influenced by factors beyond tube caliber.The principal advantage of the extended, adjustable-length design lies in its ability to optimize intratracheal positioning, allowing the cuff to be positioned distal to the most dilated airway segment and reducing reliance on excessive cuff inflation. Additionally, these tubes are typically equipped with larger, more compliant high-volume cuffs, which better accommodate tracheomegaly and have been shown to reduce refractory air leak when standard-length tubes require high cuff inflation volumes 16–17. Accordingly, the benefit of adjustable tracheostomy systems in this setting appears to be driven primarily by positional flexibility and cuff geometry rather than tube diameter alone 18.This approach proved successful, as evidenced by the gradual resolution of SE. To our knowledge, this is the first report on massive SE caused by trachea – tracheostomy tube size mismatch, combined with the fenestrations and wound dehiscence managed with an upsized, non-fenestrated, flexible wire-reinforced cuffed tracheostomy tube as a primary strategy to address the massive post-tracheostomy SE.Conclusion: Massive subcutaneous emphysema following tracheostomy is an uncommon but potentially serious complication, particularly when associated with pneumomediastinum. This case highlights the importance of identifying anatomical and device-related contributors to persistent air leakage, including tracheal caliber mismatch, fenestrations, and subtle stoma dehiscence. When conservative measures fail, early, targeted intervention is warranted. Upsizing to a non-fenestrated, flexible, wire-reinforced tracheostomy tube with an adjustable flange provided an effective seal, optimized intratracheal positioning, and led to complete resolution without additional invasive procedures. Careful tube selection and fit should be considered central to the management algorithm of massive post-tracheostomy SE.
