We describe a 75-year-old female with a known long tracheal stenosis who underwent an open tracheostomy after complicated coronary artery bypass grafting surgery in 2005. She was weaned off the tracheostomy and had not required any intervention to the trachea. She presented with recurrent episodes of congestive cardiac failure, requiring prolonged mechanical ventilation. A technically challenging redo open tracheostomy was performed. Her initial postoperative course was uneventful. However, she developed respiratory distress with high airway pressure the next day. Bronchoscopic surveillance showed the tracheostomy tube abutting the narrowed trachea posteriorly. There was a short segment of pristine trachea 3 cm above the carina. Hence a decision was made to change to a longer tracheostomy tube to bypass the tracheal stenosis. During this difficult procedure, a 2 cm tracheal laceration was inadvertently created along the side of the trachea. Meanwhile, she was unknowingly ventilated via a bag and valve mask. With difficulty, the new tracheostomy tube was then secured in optimal position under bronchoscopic guidance.
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