Bilateral pneumothorax as a complication of changing tracheostomy tube.

A 43-year-old man with adult respiratory distress syndrome, secondary to pneumonia, developed bilateral pneumothorax on the fifth post-tracheostomy day, when the tracheostomy tube was being changed to a larger size tube in order to control bleeding from the tracheostomy site. This case demonstrates the potential danger of changing the tube in the postoperative period.