Pneumomediastinum and pneumoperitoneum caused by tracheostomy displacement

A 20-year-old woman with a history of morbid obesity secondary to Prader-Willi syndrome and recent acute-on-chronic respiratory failure requiring tracheostomy placement presented to the emergency department of a regional hospital with respiratory distress and concern for tracheostomy obstruction. Her tracheostomy was exchanged, and mechanical ventilation was initiated prior to transfer to our hospital. She continued to experience respiratory distress; plain chest radiography demonstrated pneumomediastinum (figure 1A). Dedicated CT of the chest and abdomen demonstrated a left-sided pneumothorax, pneumomediastinum and pneumoperitoneum, which appeared to track down from the thoracic cavity (figure 1B–D). At the time, the patient was in acute kidney failure and urine output was decreased. Bladder pressure …