Silent Post-intubation Tracheal Stenosis Unmasked by Status Epilepticus in a Paediatric Neurotrauma Survivor: A Triple Jeopardy Airway Crisis

Post-intubation tracheal stenosis (PITS) can remain clinically silent until a physiological stressor precipitates life-threatening airway failure. This case report describes a 15-year-old male, a survivor of traumatic brain injury requiring prolonged endotracheal intubation, who presented in active convulsive status epilepticus with a Glasgow Coma Scale score of 4 and oxygen saturation of 43%. Sequential endotracheal intubation with three tube sizes failed, establishing a cannot intubate, cannot oxygenate (CICO) scenario. Emergency flexible bronchoscopy, performed with a laryngeal mask airway as a ventilatory bridge, revealed fully mobile vocal cords but a pinpoint subglottic lumen through which the bronchoscope could not advance, consistent with Myer-Cotton Grade III-IV PITS. Critical respiratory acidosis was confirmed: pH 6.95, partial pressure of carbon dioxide (pCO2) 135 mmHg. Emergency surgical tracheostomy under local anaesthesia restored ventilation. CT of the neck confirmed circumferential tracheal wall thickening extending 2.3 cm below the subglottis. The patient was weaned from mechanical ventilation and discharged on hospital day 11 with planned outpatient tracheal reconstruction. This case introduces the triple jeopardy airway crisis: the convergence of active status epilepticus, occult mechanical airway obstruction, and critical respiratory acidosis, and illustrates that successful CICO management in this setting demands anatomical contextualisation beyond algorithmic adherence.