Delayed Tracheal Wall Injury Following Percutaneous Tracheostomy Tube Exchange Resulting in Pneumomediastinum: A Case Report

A tracheal wall injury is a rare but serious complication of percutaneous dilatational tracheostomy (PDT). Most tears occur during the index procedure; delayed posterior membranous rupture after routine tube exchange is uncommon and may present subtly until significant airway or mediastinal compromise develops. We report a 66-year-old woman who developed rapidly progressive subcutaneous emphysema, hypoxia, and early tension physiology shortly after a routine tracheostomy tube exchange performed eight days after an initially uncomplicated PDT. Imaging revealed extensive pneumomediastinum, and bronchoscopy identified a longitudinal posterior tracheal tear 1-2 cm above the carina. Management required immediate decompression, temporary orotracheal intubation, and placement of an adjustable long-flange tracheostomy tube beyond the defect, followed by definitive endoluminal stenting. This strategy stabilized the airway and prevented further mediastinal air leak. Delayed tracheal injury following tracheostomy tube exchange is an under-recognized cause of acute subcutaneous emphysema and respiratory deterioration. Early suspicion, bronchoscopic confirmation, rapid decompression when tension physiology is present, and individualized airway reconstruction, including distal tube positioning or stenting, are critical to preventing catastrophic outcomes.