Dear Editor, An 88-year-old woman presented to our emergent department with sudden onset of respiratory distress and cold sweating after witness chocking. On arrival, her consciousness became like unclear and her vital signs were as: temperature of 35.9°C, pulse rate of 86/min, respiratory rate of 20/min, and blood pressure of 131/94 mmHg. The pulse oximeter showed the SpO ₂ as only 77% on ambient air. Emergent endotracheal intubation was performed for acute hypoxic respiratory failure. However, the process of intubation was not smooth. The endotracheal tube was finally inserted by a senior doctor after two attempts. After several minutes, subcutaneous emphysema developed and chest radiography showed extensive subcutaneous emphysema and pneumothorax on the right side (Figure-1). Further computed tomography (CT) confirms the presence of pneumomediastinum, right pneumothorax and diffuse subcutaneous emphysema over neck, chest and abdominal wall (Figure-2). Emergent pleural drainage was done for right pneumo thorax. Under impression of tracheal injury, bronchoscopic examination was done and showed a tiny perforation over the carina (Figure-3). After condition stabilized, she was admitted to intensive care unit. Thereafter, the subcutaneous emphysema and pneumothorax gradually resolution and respiratory condition improved during ICU hospitalization. Finally, she was successfully extubated two weeks later and uneventfully discharged three weeks later. The entotracheal intubation is a life-saving intervention for patients with acute respiratory failure. However, this procedure can also be associated with several complications, such as tracheobronchial rupture. In one systematic review, the prevalence of the endotracheal intubation associated with tracheobronchial injury was reported to be 27.4% of all kinds of the tracheobronchial injury ( 1 ).

The possible mechanisms included trauma during intubation, overinflation of cuff, and some anatomical factors ( 2 ). Common clinical presentations are subcutaneous emphysema, mediastinal emphysema, and pneumothorax after intubations. In most cases, conservation treatment can achieve favorable outcomes, but surgical repair should be always considered if the clinical condition doesn’t improve.