Abstract
Pneumomediastinum, pneumopericardium, and pneumothorax are recognized but rare complications associated with endotracheal intubation and mechanical ventilation in the perioperative setting. The simultaneous occurrence of all three pathologies following intubation and intraoperative repositioning has not previously been described in the literature. This case report details the presentation and management of a 64-year-old male patient with metastatic prostate cancer undergoing thoracic decompression and fusion, who developed pneumomediastinum, pneumopericardium, and bilateral pneumothoraces following endotracheal intubation and repositioning. The patient's medical history included a prior smoking history and known bullous emphysematous changes. Induction of general anesthesia was uneventful. Following repositioning from supine to prone, the patient experienced an acute ventilatory compromise characterized by elevated peak airway pressures, reduced tidal volumes, and hypotension. The endotracheal tube (ETT) was suctioned, albuterol was delivered, and the patient returned to baseline. Shortly after, another ventilatory compromise occurred. Interventions included suctioning of the ETT, administration of albuterol, conversion to manual ventilation, and a fiberoptic examination of the ETT. Chest radiography and computed tomography angiogram identified pneumomediastinum, pneumopericardium, and bilateral pneumothoraces. The patient was transferred to the surgical intensive care unit for conservative management, including serial chest radiographs, and ultimately recovered without further cardiopulmonary complications. The simultaneous occurrence of pneumomediastinum, pneumopericardium, and pneumothorax following prone repositioning during general anesthesia presents a previously undocumented complication pathway requiring rapid diagnosis and management. Future work should explore standardized protocols for early recognition and intervention in "can intubate, cannot ventilate" scenarios, as well as preventive ventilatory strategies in patients with underlying pulmonary pathology.