A 78-year-old female was transferred to our hospital for the treatment of myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis, one of the rapidly progressive forms of glomerulonephritis. She had a history of diabetes mellitus. On the 2nd day of hospitalization, we initiated steroid pulse therapy followed by oral prednisolone. On the 30th day, we added intravenous cyclophosphamide administration. On the 31st day, she suddenly developed severe respiratory failure requiring mechanical ventilation in the intensive care unit (ICU). She was diagnosed with cytomegalovirus pneumonia, and ganciclovir administration was initiated. On her 12th day in the ICU, she was extubated and underwent a minitracheostomy as she still had a poor cough reflex. The minitracheostomy was safely constructed by adequately trained anesthesiologists and a surgeon using a video bronchoscope. On the 16th day, the minitracheostomy tube was removed after the improvement in tracheal clearance, and she returned to the normal ward. That night, she suddenly exclaimed in delirium. Physical examination revealed palpable crepitus in the chest. Computed tomography showed a remarkable pneumomediastinum (Fig. 1). We speculated that much air had entered into the mediastinum through the tracheostomy hole when the patient shouted vigorously. Vigorous shouting might increase the respiratory effort and cause alveolar rupture. The pneumomediastinum spontaneously resolved in 3 weeks.
Figure 1 .
The massive pneumomediastinum was detected.
Minitracheostomy is a minimally invasive procedure that aims to facilitate tracheal suctioning and clear secretions [1]. Complications rarely occur, such as bleeding, incorrect placement of the minitracheostomy tube and subcutaneous emphysema around the tube [2–4]. The tract generally gets sealed within 3 days [2]. In our case, the presence of risk factors such as diabetes and the use of steroids could have caused poor wound healing at the tracheostomy site. In conclusion, our case highlights the importance of close and careful monitoring of a tracheostomy site for 24–48 hours after de-cannulation by respiratory therapists, nurses and physicians.
ACKNOWLEDGEMENTS
The authors have no acknowledgements to declare.
CONFLICT OF INTEREST STATEMENT
No conflicts of interest.
FUNDING
The authors have no funding sources to declare.
ETHICAL APPROVAL
This case study complied with the Helsinki Declaration standards and was approved by the Ethical Committee of Nippon Medical School Hospital.
CONSENT
Informed consent was obtained by the patient.
GUARANTOR
Sae Aratani is a guarantor of this paper.
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