Diagnosis by forensic autopsy of cannula malposition resulting in fatal tension pneumothorax after attempted percutaneous tracheostomy: A short communication

J Forensic Leg Med. 2021 Jul;81:102177. doi: 10.1016/j.jflm.2021.102177. Epub 2021 May 6.


Percutaneous tracheostomy is commonly performed in the emergency department or intensive care unit to secure the airways of patients. This procedure is associated with a low incidence of complications; however, some of them, such as iatrogenic pneumothorax, can be fatal. Pneumothorax after percutaneous tracheostomy is most often caused by perforation of the tracheal wall or malposition of the cannula. A woman in her 80s was referred to the emergency department owing to persistent and prolonged coughing. Having speculated that she had acute epiglottitis, and having failed to achieve oral tracheal intubation, the physician performed a percutaneous tracheostomy to secure her airway. However, progressive percutaneous emphysema developed immediately thereafter, and the patient died shortly. Postmortem computed tomography showed bilateral pneumothorax. Forensic autopsy revealed that the tracheostomy cannula had failed to reach the trachea and was erroneously inserted into the right thoracic cavity via peritracheal route. Thus, it was determined that the patient's death was attributable to tension pneumothorax caused by cannula malposition during attempted tracheostomy. To the best of our knowledge, this is the first forensic autopsy case report on fatal tension pneumothorax caused by attempted percutaneous tracheostomy.

Keywords: Autopsy; Forensic science; Pneumothorax; Tracheostomy.

Publication types

  • Case Reports

MeSH terms

  • Aged, 80 and over
  • Cannula / adverse effects*
  • Fatal Outcome
  • Female
  • Humans
  • Intubation, Intratracheal / adverse effects*
  • Medical Errors / adverse effects
  • Pneumothorax / etiology*
  • Thoracic Cavity / diagnostic imaging
  • Tracheostomy / adverse effects*