[Pneumothorax, subcutaneous emphysema and mediastinal emphysema in transnasally intubated patients].

A 41-year-old woman was admitted to our clinic because of an acute subdural hematoma. After an emergency operation her neurological status improved with an increase in the Glasgow Coma Scale score from 6 to 11. On the second postoperative day she developed frequent episodes of clonic convulsive seizures localized in the face and the left upper extremity, and her level of consciousness deteriorated. Next day she was transnasally intubated for respiratory management, but no mechanical ventilation was required. While she was undergoing the CT scanning 5 days after intubation, respiratory arrest and cyanosis developed all of a sudden, and her face and neck became swollen. The chest x-ray revealed a marked subcutaneous emphysema, mediastinal emphysema and bilateral pneumothorax. CT at that time showed a diffuse low density area in the right hemisphere, and a marked midline shift returned. She did not regain consciousness and died 12 days after the incident. At autopsy an ulcer was observed in the wall of the trachea, where the tip or the cuff of the transnasal tracheal tube was supposed to be present. No perforation, however, was there. Case 2: A 75-year-old woman was admitted to our hospital because of SAH. In hospital course she was also transnasally intubated and required no mechanical ventilation. When she was undergoing the CT scanning 3 days after intubation, she developed subcutaneous and mediastinal emphysema similarly to case 1. Although it is reported to be not a rare complication in patients on a mechanical ventilator, subcutaneous emphysema or pneumothorax is extremely rare in those intubated patients with spontaneous respiration. The mechanism of these complications in these cases is briefly discussed.