Peri-tracheostomy Cuff Herniation: Unlisted Cause of Air Leak during Mechanical Ventilation

REPORTworsening bilateral consolidation.Accordingly, hypoxemia worsened, requiring higher ventilator settings necessitating sedation and paralysis.Ventilator graphs showed a leak of around 100 mL, which was evident clinically by gurgling sounds around the TT and in the oral cavity.He also had secretions coming through his nostrils during expiration.The leak worsened, leading to an increased need for ventilator parameters due to worsening hypoxemia.This cycle of increasing ventilator support further worsened the leak, and hypoxemia continued.In order to reduce the leak, the TT cuff pressure had to be increased to 70 cm H 2 0, which was later reduced.The patient did not have subcutaneous emphysema or neck swelling at any time during the course of his illness.Assuming the cuff leak could be overcome by a larger TT, the TT size was increased to 8.5 mm.However, the leak was still persisting, along with worsening hypoxemia and hypercapnia.A multidisciplinary clinical team comprising ear, nose, throat, anesthesia, and critical care unit discussed and opined to rule out tracheomalacia, tracheal injury, and tracheoesophageal fistula.The video laryngoscope did not yield any clue due to