Rapidly Progressive Subcutaneous Emphysema and Sequential Bilateral Pneumothoraces Following Pediatric Tracheocutaneous Fistula Closure: A Postoperative Air-Leak Syndrome Recognized in the Post-anesthesia Care Unit (PACU).

Tracheocutaneous fistula (TCF) closure is commonly performed in pediatric patients following successful decannulation from long-term tracheostomy dependence. Although the procedure is generally considered safe, postoperative air-leak complications, including subcutaneous emphysema, pneumomediastinum, and pneumothorax, have been reported. Early recognition is critical because progression may lead to significant respiratory compromise. We report the case of a three-year-old child who developed rapidly progressive subcutaneous emphysema in the post-anesthesia care unit (PACU) following TCF closure after direct laryngoscopy and bronchoscopy. The patient subsequently developed massive subcutaneous emphysema that progressed to bilateral pneumothoraces requiring emergent chest tube placement and intensive care management. This case highlights the potential for rapid progression of postoperative air-leak syndromes following pediatric airway surgery and emphasizes the importance of early recognition by anesthesia providers during the immediate postoperative period. Awareness of the clinical presentation of subcutaneous emphysema and its potential progression to pneumomediastinum and pneumothorax is essential to prevent life-threatening complications.