A 55-year-old woman undergoes elective tracheostomy for laryngeal papillomatosis requiring repeated laser ablations. On postoperative day 3, she develops sudden-onset stridor, subcutaneous emphysema around the stoma, and respiratory distress. Oxygen saturation drops to 88% despite supplemental oxygen. What is the most appropriate immediate next step?

Explanation

## Clinical Diagnosis The constellation of sudden stridor, subcutaneous emphysema, and respiratory distress on postoperative day 3 is highly suggestive of **tracheal perforation** — a surgical emergency. ## Pathophysiology of Tracheal Perforation **Key Point:** Tracheal perforation can occur during: - Tube insertion (direct trauma) - Excessive cuff pressure (ischaemic necrosis) - Tube migration and erosion - Excessive tube movement **High-Yield:** Subcutaneous emphysema is the hallmark sign of tracheal breach — air escapes into the mediastinum and soft tissues, causing: - Stridor (airway obstruction) - Respiratory distress - Crepitus on palpation - Risk of tension pneumomediastinum ## Why Immediate Tube Removal and Exploration? | Step | Rationale | | --- | --- | | **Remove tube** | Stops further air leak and allows direct visualization | | **Inspect trachea** | Identifies perforation site and size | | **Prepare for surgery** | Perforations >50% circumference require primary repair | | **Prevent mediastinitis** | Reduces risk of life-threatening infection | **Clinical Pearl:** Tracheal perforation is a **surgical emergency**. Delay in diagnosis and treatment increases mortality from mediastinitis and sepsis. The presence of subcutaneous emphysema + stridor + respiratory distress is a "red flag" triad. ## Management Algorithm ```mermaid flowchart TD A[Post-tracheostomy stridor + subcutaneous emphysema]:::outcome --> B{Tracheal perforation suspected?}:::decision B -->|Yes - confirmed by clinical signs| C[Remove tracheostomy tube immediately]:::action C --> D[Inspect trachea for breach]:::action D --> E{Perforation size?}:::decision E -->|Small <50%| F[Conservative: observe, broad-spectrum ABx]:::action E -->|Large ≥50%| G[Urgent surgical repair + primary closure]:::action G --> H[Prevent mediastinitis]:::outcome B -->|No - tube malposition| I[Reposition or upsize tube]:::action ``` **Mnemonic — Complications of Tracheostomy ("STENT"):** - **S**tenosis (late, 2–4 weeks) - **T**ube obstruction (early, mucus plugging) - **E**rosion and perforation (early–late, cuff pressure) - **N**ecrotizing tracheitis (infection) - **T**ube migration (early, displacement) ## Why This Answer is Correct Removing the tube stops further air leak, allows direct inspection of the trachea, and enables urgent surgical repair if perforation is confirmed. This is the only approach that addresses the underlying emergency.