Subcutaneous emphysema localized to the area of a transtracheal needle puncture site is common but self-limited. In severe cases, air may track through the fascial planes of the neck, leading to tracheal compression with airway compromise, pneumomediastinum, and pneumothorax. Accumulation of air occurs gradually (1 to 6 hours) after a transtracheal puncture. Severe subcutaneous emphysema has been attributed to use of a large-bore needle, multiple CTM punctures, and exposure of the puncture site to persistent elevated intratracheal pressure (coughing, grunting, or sneezing). In addition, pneumomediastinum has been reported in patients who underwent transtracheal puncture with a needle and was attributed to elevated endotracheal pressure (paroxysmal coughing and sneezing). When the patient has been intubated by the retrograde technique, elevated peak inspiratory pressure (PIP) and elevated end-expiratory pressure (PEEP) should not increase the likelihood of these complications intraoperatively, because the puncture site is located above the ETT cuff, so that the area of the initial puncture site is not exposed to high pressure. Lee and coauthors reported on a patient with a history of noncardiogenic pulmonary edema and atelectasis who, after RI, received 7.5 cm H2O with PEEP with no complications (PIP values were not reported)