Department of Anaesthetics, Royal Brompton Hospital, Sydney Street, London SW6 6NP, UK
* Corresponding author: Department of Anaesthetics, Morriston Hospital, Morriston, Swansea SA6 6NL, UKE-mail: davidjwilliams{at}doctors.org.uk
Accepted for publication October 26, 2004.
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() |
---|
Keywords: complications, upper airway emergency ; complications, upper airway obstruction ; complications, subcutaneous emphysema ; complications, pneumothorax ; complications, pneumomediastinum ; equipment, chest drain ; equipment, chest tube drainage ; equipment, pacemaker
![]() |
Case history |
---|
![]() ![]() ![]() ![]() ![]() |
---|
On admission, she gave a history of exertional dyspnoea, orthopnoea, and chest pain on walking 10 m. On examination, she had pitting ankle oedema and a palpable 4-cm liver edge. Heart sounds were inaudible and jugular venous pulsation could not be seen. There was diffuse bilateral wheeze on auscultation of the chest. Arterial blood gases on oxygen 24% were: 88%,
6.33 kPa,
7.88 kPa, H+ 44 mmol litre1.
A PPM was inserted via the left subclavian vein using midazolam sedation and local anaesthesia with lidocaine. The PPM functioned correctly; however, the procedure was technically difficult and resulted in an iatrogenic pneumothorax occupying 30% of the left chest. This was immediately recognized during the procedure and confirmed on chest X-ray. A left intercostal drain (ICD) was therefore inserted under local anaesthesia and connected to 5 cm suction via an underwater seal, resulting in re-expansion of the lung.
Five days later, the underwater seal was still bubbling, but the ICD was accidentally removed by nursing staff. Within minutes, the patient developed gross and rapidly progressive surgical emphysema extending from the groin to the neck, face and hands (Figs 1 and 2), with a hoarse voice, respiratory distress, and stridor (ventilatory frequency 30 bpm, heart rate 110 beats min1, blood pressure 130/80 mm Hg). On auscultation, bilateral breath sounds were present. Oxygen was administered via face mask, the anaesthetic team was called, and the patient was transferred immediately to the operating theatre. The surgical team was also called, and preparations made for emergency tracheostomy if necessary.
|
|
The patient was sedated with propofol and transferred to the intensive care unit (ICU). A CT scan revealed persisting large left and smaller right pneumothoraces, with gross subcutaneous emphysema of the chest wall (Fig. 3). Despite these findings, the PPM continued to function normally. A further ICD was inserted under local anaesthesia to facilitate drainage of the left pneumothorax, and a nasogastric tube was inserted to facilitate feeding.
|
Weaning was prolonged as a result of the persistent air leak, surgical emphysema, COPD, and body habitus. Formal tracheostomy was therefore performed 7 days after admission to ICU. The chest drains stopped bubbling and were removed 20 days after insertion. Artificial ventilation was discontinued, and the patient was discharged home on a reducing dose of oral steroids 10 days later. On review in the outpatient clinic a month after discharge, she remained well and the surgical emphysema had completely resolved.
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() |
---|
In addition, subcutaneous emphysema may be associated with tension pneumothorax,11 and tension pneumopericardium,3 causing respiratory failure and reduction in cardiac output.
It is notable that this patient developed gross, life threatening, tension subcutaneous emphysema before positive pressure ventilation was commenced. A possible cause of this development could have been a pressure gradient between the alveoli and subcutaneous tissues arising from alveolar air-trapping secondary to COPD. The patient had no history of angioedema or recent changes in medication to suggest an allergic cause for the rapid, generalized tissue swelling.
Dissection of air into the soft tissues of the neck in this condition can cause sore throat, dysphagia, dysphonia, stridor and dyspnoea, and may resemble the symptoms of epiglottitis.3 If the patient's condition permits, plain chest and lateral soft-tissue X-rays of the neck may aid diagnosis. Fibre-optic nasopharyngeal laryngoscopy may aid assessment of airway obstruction.3 However, these investigations should not delay definitive management. In the great majority of patients, subcutaneous emphysema resolves spontaneously over several days. High-flow oxygen therapy speeds resolution by facilitating resorption of nitrogen from the distended tissues and pneumomediastinum.3 12 Restriction of ventilation from subcutaneous emphysema of the chest wall may be relieved by incision,8 or by insertion of large-bore subcutaneous drains connected to an underwater seal or suction.6 13 14
Symptoms suggestive of airway obstruction require immediate intervention. Tracheal intubation and emergency tracheostomy (if the former is unsuccessful) may both be extremely difficult, and should be performed by an experienced anaesthetist and surgeon in the operating theatre with immediate access to additional staff and equipment. The anaesthetic technique depends on the patient's clinical condition and the judgement of the anaesthetist, but may include inhalation or i.v. induction, awake fibre-optic intubation, or awake tracheostomy under local anaesthesia.
Clinically significant pneumothorax requires ICD insertion, and pneumopericardium requires decompression using a pericardial needle.3 Release of air from tension subcutaneous emphysema may mimic the release of a tension pneumothorax, with an audible hiss on insertion of the ICD, and bubbling of the underwater seal drain.15 A chest X-ray should be performed following insertion to confirm correct placement.
An ICD that is still bubbling should never be clamped or removed, as this may convert a simple pneumothorax into a tension pneumothorax. Some institutions routinely clamp ICDs during transfer from the operating table on the grounds that this will prevent disruption or possible reflux of the underwater seal into the pleural cavity if the drainage bottle is lifted during this process. However, provided that the drainage bottle is kept 1 m below the level of the patient, reflux should not occur and the seal should remain intact. Alternatively, substitution of the underwater seal for a Heimlich valve may provide a safe and effective system for transfer.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() |
---|
2 Gibney R, Finnegan B, Fitzgerald M, Lynch V. Upper airway obstruction caused by massive subcutaneous emphysema. Intensive Care Med 1984; 10: 434[ISI][Medline]
3 Caraballo V, Barish R, Floccare D. Pneumomediastinum presenting as acute airway obstruction. J Emergency Med 1996; 14: 15963[CrossRef][Medline]
4 Tonnesen A, Wagner W, Mackay-Hargadine J. Tension subcutaneous emphysema. Anesthesiology 1985; 62: 902[ISI][Medline]
5 Coelho J, Tonnensen A, Allen S, Miner M. Intracranial hypertension secondary to tension subcutaneous emphysema. Crit Care Med 1985; 13: 5123[ISI][Medline]
6 Kelly M, McGuigan J, Allen R. Relief of tension subcutaneous emphysema using a large bore subcutaneous drain. Anaesthesia 1995; 50: 10779[ISI][Medline]
7 Conetta R, Barman A, Iakovou C, Masakayan R. Acute ventilatory failure from massive subcutaneous emphysema. Chest 1993; 10: 97880
8 Eveloff S, Donat W, Aisenberg R, Braman S. Pneumatic chest wall compression. Chest 1991; 99: 10213[Abstract]
9 Hearne S, Maloney J. Pacemaker system failure secondary to air entrapment within the pulse generator. Chest 1982; 82: 6513[Abstract]
10 Beg M, Reyazuddin, Ansari M. Traumatic tension pneumomediastinum mimicking cardiac tamponade. Thorax 1988; 43: 5767[Abstract]
11 Herbst C. Indications, management and complications of percutaneous subclavian catheters. Arch Surg 1978; 113: 14215[Abstract]
12 O'Neill T, Johnson M, Edwards D, Dietz P. Ventilation with one hundred percent oxygen for life threatening mediastinal and subcutaneous emphysema. Chest 1979; 76: 492
13 Herlan D, Landreneau R, Ferson PF. Massive spontaneous subcutaneous emphysema. Acute management with infraclavicular blow holes. Chest 1992; 102: 5035[Abstract]
14 Terada Y, Matsunobe S, Nemoto T, Tsuda T, Shimizu Y. Palliation of severe subcutaneous emphysema with use of a trocar-type chest tube as a subcutaneous drain. Chest 1993; 103: 323
15 Beese E, Broome I. A complication of intercostal insertion of a chest drain. Br J Anaesth 1988; 61: 6423