DEBILITATING SUBCUTANEOUS EMPHYSEMA IN THE SETTING OF RESOLVING SECONDARY PNEUMOTHORAX

Abstract

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Subcutaneous emphysema (SE) is defined as the presence of air under subcutaneous tissues manifesting as swelling and crepitus. This typically benign self-limiting condition can rapidly deteriorate if left unchecked. We present a case of debilitating SE in the setting of pneumothorax management. CASE PRESENTATION: A 72-year-old man with severe chronic obstructive pulmonary disease presented with an iatrogenic small right-sided pneumothorax immediately after CT-guided biopsy of a pulmonary nodule. He improved after right thoracostomy tube insertion. Twenty-four hours after removal of the tube, he experienced dyspnea and chest pain. Physical exam was pertinent for absent breath sounds on the right hemithorax. A new moderately sized right sided lateral pneumothorax was noted on emergent chest x-ray. Due to worsening respiratory failure, he underwent intubation prior to being transferred to the intensive care unit. Upon chest tube placement, he was noted to have extensive crepitus on the bilateral neck, right hemithorax, abdomen, and pelvis. He was successfully extubated and repeat imaging confirmed resolution of pneumothorax with complete lung re-expansion, thus the chest tube was shifted from suction to water seal. Five minutes after, the subcutaneous emphysema rapidly progressed to involve the entire face as evidenced by worsening bilateral periorbital edema, closure of palpebral fissures, and high patient distress. Infraclavicular blowhole incisions were then placed and the chest tube was placed back on 20 mmHg suction. He was continued on suction for three more days until eventual resolution of the subcutaneous emphysema. DISCUSSION: SE is defined as de novo infiltration of air in the subcutaneous layers of the skin. Potential causes include surgeries, trauma, infections, and idiopathic etiology, with an incidence of 0.43% to 2.34%. Complications of extensive SE include dysphagia and compression of the airway, barotrauma, expanding pneumothorax, reduced cardiac preload, skin necrosis, amongst others. Debilitating features include anxiety, dysphagia, dysphonia, and significant respiratory or circulatory compromise. Our patient had a higher risk for SE due to the timing of the thoracotomy tube insertion while the patient was exposed to positive pressure. Worsening of the SE was due to premature discontinuation of chest tube suction. Although the pneumothorax has already resolved, it is prudent to delay transitioning the suction to water seal until the SE has stabilized. Infraclavicular blow-hole incisions, subcutaneous drains, fenestrated angiocatheters, vacuum assisted dressings and increasing suction on a pre-existing chest tube have also been described to expedite the time to recovery from debilitating SE CONCLUSIONS: Early identification and management are essential to decrease SE-related complications and mortality. More studies are needed to explore ideal management options. REFERENCE #1: Aghajanzadeh M, Dehnadi A, Ebrahimi H, Fallah Karkan M, Khajeh Jahromi S, Amir Maafi A, Aghajanzadeh G. Classification and Management of Subcutaneous Emphysema: a 10-Year Experience. Indian J Surg. 2015 Dec;77(Suppl 2):673-7 REFERENCE #2: Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med. 1984 Jul;144(7):1447-53 REFERENCE #3: Jones P, Hewer R, Wolfenden Het al. Subcutaneous emphysema associated with chest tube drainage. Respirology 2001; 6(2): 87–89 DISCLOSURES: No relevant relationships by Gustavo Avila, source=Web Response No relevant relationships by Jessica Baek, source=Web Response No relevant relationships by Renuka Reddy, source=Web Response No relevant relationships by Jodi Renner, source=Web Response No relevant relationships by Larnelle Simms, source=Web Response No relevant relationships by Laura Suzanne Suarez, source=Web Response No relevant relationships by Claudia Tejera Quesada, source=Web Response