2025 FSA Podium and Poster Abstracts

Introduction/Background: Post-intubation tracheal injuries (PITI) are rare but can be life-threatening if not promptly recognized and managed. Incidence ranges from 0.005% in single-lumen endotracheal tube intubations to 15% in emergency procedures. Risk factors include difficult airway scenarios, multiple intubation attempts, use of stiff introducers or stylets, cuff overinflation, chronic obstructive pulmonary disease, and corticosteroid therapy. The posterior membranous portion of the trachea is most commonly involved, often presenting with subcutaneous emphysema, pneumomediastinum, or pneumothorax. While surgical repair has traditionally been considered for significant tracheal tears, recent literature increasingly supports conservative management for select patients who are hemodynamically stable, have smaller tears (<4 cm), and lack signs of mediastinitisor esophageal involvement. We present a case of PITI in an 82-year-old female following a difficult intubation for coronary artery bypass grafting (CABG), highlighting the diagnostic course, conservative treatment, and key preventive measures.

Methods: A single patient case was analyzed from records collected on an 82-year-old femalewith a history of hypertension, hyperlipidemia, coronary artery disease, and depression who underwent CABG. Information regarding her anesthetic course, intubation details, postoperative complications, diagnostic imaging (chest radiographs and computed tomography), and clinical progress were extracted. A focused literature review of PITIwas conducted.

Results: Patient was induced with standard intravenous anesthetics. On direct laryngoscopy, a Grade 3 view was encountered. A bougie-assisted technique was used. Surgery proceeded uneventfully. Postoperatively, the patient was extubated on postoperative day and did well on supplemental oxygen via nasal cannula.

Beginning on POD 1, patient developed supraventricular tachycardia and atrial fibrillation requiring amiodarone infusion and increasing vasopressors. She was treated for a suspected Type 2 NSTEMI and shock liver with volume resuscitation and milrinonefor right heart failure (RHF). On POD 3, subcutaneous (SQ) emphysema was noted in the bilateral chest and neck. Chest radiography showed pneumomediastinum with chest wall emphysema, prompting the creation of bilateral 2 cm “blowhole” incisions to relieve pressure. Despite temporary improvement, recurrent SQ emphysema on POD 6revealed moderate to severe pneumomediastinum with a focal outpouching in the posterior tracheal wall at the thoracic inlet.

Over days (POD 7–9), patient remained stable on room air and subcutaneousemphysema gradually improved. Imaging confirmed a posterior tracheal wall defect but showed no evidence of esophageal involvement or mediastinitis. Cardiothoracic surgery recommended conservative management given the patient’s stability, lack of progressive infection, and the tear’s small size. Treatment included observation, strict cough suppression, and broad-spectrum antibiotics. Patient did not require reintubationand was discharged on POD 14.

Discussion/Conclusion: This case highlights the diagnostic and management challenges of a rare complication—post-intubation tracheal rupture—following a difficult intubation using a bougie. PITI should be considered in any post-intubation patient who presents with unexplained subcutaneous emphysema, pneumomediastinum, or respiratory distress. Early detection, imaging, and multidisciplinary collaboration are paramount to achieving favorable outcomes. This case underscores the importance of careful airway manipulation, prompt recognition of complications, and a tailored, stepwise approach to management—whether conservative or surgical—based on each patient’s clinical status and the extent of injury.