Subcutaneous emphysema (SE) is rarely life threatening and usually does not require treatment as the air trapped in the integuments is spontaneously absorbed within several days. However, “massive emphysema” may create substantial discomfort to patients impeding eye opening, swallowing or causing respiratory distress. In such cases, the air accumulated in the tissues should be released.

We present two cases of subcutaneous emphysema in which skin incisions, “blow holes” in the subclavicular regions were successfully used to release the air from the tissues [1].

CASE REPORTS

Case 1.

A 64-year-old male was admitted to ITU after blunt chest trauma sustained during a traffic accident. On admission the patient was conscious (GCS − 13) yet due to respiratory failure ventilation was commenced. Massive subcutaneous emphysema affecting the thoracic cavity, head and neck was observed (Fig. 1).

CT of the chest (Fig. 2) revealed numerous traumatic bony lesions, mainly on the left side: intra-articular fracture of the posterior rib III at the costovertebral joint, unstable double fractures of ribs IV – XII at their costovertebral junctions and lateral segments. In the anterior-posterior part of the left pleural cavity, slight pneumothorax, 10 mm thick, accompanied by trace amounts of fluid was visible. On the right side, a facture of the anterior segment of the rib II, fractures of anterior-lateral ribs V and VI were found. Additionally, emphysema, 25 mm thick, and a slight amount of fluid in the right pleural cavity were observed. Lung contusion involved the posterior-inferior parts and was slightly larger on the left side with atelectasis of the posterior segments of the interior lobe. Subcutaneous emphysema affected the thoracic wall and was slightly larger on the left side. No injuries of the CNS, long bones, spine or abdominal organs were found.

In ITU, the drain was inserted into the right pleural cavity and lung ventilation with BIPAP (bi-level positive airway pressure) was administered for 4 h with 14 cm H2O PEEP, (1.3 KPa) in order to maintain PaO2 >50 mm Hg (6.67 kPa), 100% oxygen in the ventilatory mixture was necessary. Gas exchange in the lungs improved during the next hours of therapy and ventilation was continued at FIO2 0.5 with PEEP 8 cm H2O (0.78 kPa). Despite the drainage, emphysema of the head, neck and thoracic cavity increased and the patient looked monstrously. Therefore, on day 3 the decision was made to “degas the tissues”. In both subclavicular regions, several 2-cm incisions of the skin and subcutaneous tissue (blow holes) were made. On incising, a hiss of escaping air was heard. During the subsequent days, clinical and radiological features of subcutaneous emphysema substantially decreased. On day 5, the drain was removed from the right pleural cavity. On day 7, ventilation was discontinued, the endotracheal tube removed and the patient was transferred to the surgical ward.

Case 2.

A 42-year-old male presented to the emergency department with the injuries to the head, neck, thorax and abdomen sustained in a violent assault. The examinations excluded intracranial haemorrhage and damage to thoracic and abdominal organs. The patient did not consent for hospitalization and was discharged home. Three days later, he reported again due to difficult swallowing and progressing oedema of the neck and face. He was conscious; circulation was efficient. He did not complain of dyspnoea or difficulties in respiration. Massive subcutaneous emphysema extending to the neck, face and thorax was clearly visible.

The radiological examination showed: the fracture of the hyoid bone, ribs VIII and IX in the posterior axillary line on the right and X and XI on the left in the paravertebral line and of the Th10 spinous process and slight pneumothorax on the right side. Slight traumatic lesions were accompanied by massive pneumomediastinum involving all compartments with the free air filling the pericardial sac and peri-aortic area (Fig. 3). Moreover, massive emphysema of the muscles and subcutaneous tissue of the head, neck, thorax and abdominal cavity was observed extending also to the scrotum and the subcutaneous tissue of the limbs. Laryngoscopy did not reveal other injuries; due to rapidly progressing emphysema, tracheostomy was performed. Pneumothorax did not require drainage.

After surgery, the patient breathed spontaneously through the tracheostomy tube with oxygen-enriched air. The menstrual emphysema of the facial tissues, however, prevented mouth opening and the contact with those around him was hindered. Therefore, at hour 12 after admission, decompression of emphysema was attempted. Under infiltration anaesthesia, several 2-cm deep incisions of the skin and subcutaneous tissue in the subclavicular regions were performed through which air immediately escaped (Fig. 4). Emphysema subsided quickly and the patient could open his eyes on the following day. 

The cause of such extensive subcutaneous emphysema was likely to be the fracture of the hyoid bone since other injuries were excluded. During the subsequent days, emphysema rapidly subsided and general condition of the patient improved. The patient was transferred to the surgical ward after the removal of the tracheostomy tube and suturing of incisions in the subclavicular regions. On the following day, the patient was discharged home in good general condition.

DISCUSSION

Subcutaneous emphysema results from penetration of air from the airway or gastrointestinal tract to the subcutaneous tissue. The most common causes include injuries to the head, neck, thorax and abdominal cavity. Due to the most frequently observed mechanism, i.e. rupture of pulmonary alveoli, the air penetrates to the lung interstitial tissue, and along the perivascular areas to the mediastinum. If its permeation is faster than absorption, the air accumulates in various structures. Generally, the subcutaneous tissue is least resistant. Subcutaneous emphysema is characterized by tissue crepitation well detectable on palpation. The increasing gas pressure in the mediastinum may lead to pleural damage and consequently to pneumothorax. In extreme cases, subcutaneous emphysema is accompanied by anxiety, excitation, severe tissue deformity, aphonia and respiratory failure caused by airway compression [2, 3]. Moreover, the incidents of malfunction of pacemakers, pneumomediastinum and gas embolism were reported [4, 5, 6]. Mechanical lung ventilation usually increases the symptoms of emphysema, which evidences in increased skin tone, ”crepitation” of tissues, eyelid closure, increased symptoms of respiratory failure [7, 8]. Therefore, prolonged hospitalization should be expected in such cases [6, 7].

Several treatment methods for SE have been described. Many of them are too invasive or ineffective. Prophylactic insertion of drains into the pleural cavity [9] or tracheostomy seem to be of a doubtful value. The authors of numerous publications regarding this issue focus on methods accelerating the subsidence of emphysema. For this purpose blow holes in the subclavicular regions [1], subcutaneous insertion of pig-tail drains, or large bore drains are recommended [1, 10, 11, 12, 13].

In our two cases, incisions in the subclavicular regions were performed which functioned properly for several dozen hours although according to literature data the efficacy of this method decreases once the crust has formed at the incision site. Moreover, scar formation cannot be excluded [6]. In some publications, insertion of plastic catheters into the subcutaneous tissue is suggested, once numerous holes have been created in their walls [8]. This method is considered simple, painless, slightly invasive, and safe as the patient is not at risk of infection [7]. However, the effectiveness of the methods described is limited by low gradient of pressures between the interstitial compartment and atmospheric air. Therefore, to accelerate “degassing” it is recommended to massage the face, shoulders and thorax in the direction of the inserted catheters. The natural time of gas absorption from the subcutaneous tissue is estimated at 3.7 days; after insertion of catheters, the time decreases even to 12 h [8]. Further more, effective anaesthesia, inhibition of cough and oxygen therapy are found helpful.

Subcutaneous emphysema may be accompanied by marked discomfort related to the body deformity, which impedes eye opening, speaking and impairs respiration. Blow holes in the subclavicular regions are a simple, effective and safe method accelerating the subsidence of emphysema.  

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REFERENCES

1.    Herlan DB, Landreneau RJ, Ferson PF: Massive spontaneous subcutaneous emphysema. Acute management with infraclavicular “blow holes”. Chest 1992; 102: 9503-9505.

2.    Conetta R, Barman AA, Iakovou C, Masakayan RJ: Acute ventilatory failure from massive subcutaneous emphysema. Chest 1993; 104: 978-980.

3.    Gibney RT, Finnegan B, FitzGerald MX, Lynch V: Upper airway obstruction caused by massive subcutaneous emphysema. Intensive Care Med 1984; 10: 43-44.

4.    Giroud D, Goy JJ: Pacemaker malfunction due to subcutaneous emphysema. Int J Cardiol 1990; 26: 234-236.

5.    Srinivas R, Singh N, Agarwal R, Aggarwal A: Management of extensive subcutaneous emphysema and pneumomediastinum by micro-drainage: time for a re-think? Singapore Med J Case Report 2007; 48: e323.

6.    Mason RJ, Murray JF, Broaddus VC, Nadel JA: Mediastinal disorders; in: Murray and Nadel’s Textbook of Respiratory Medicine (Ed.: Murray JF, Nadel JA) Elsevier Saunders, Philadelphia 2005: 2039-2049.

7.    Beck PL, Heitman SJ, Mody CH: Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema. Chest 2002; 121: 647-649.

8.    Cesario A, Margaritora S, Porziella V, Granone P: Microdrainage via open technique in severe subcutaneous emphysema. Chest 2003; 123: 2161-2162.

9.    Mattox KL, Allen MK: Systematic approach to pneumothorax, hemothorax, pneumomediastinum and subcutaneous emphysema. Injury 1986; 17: 309-312.

10.    Kelly MC, McGuigan JA, Allen RW: Relief of tension subcutaneous emphysema using a large bore subcutaneous drain. Anaesthesia 1995; 50: 1077-1079.

11.    Crouch JD, Keagy BA, Delany DJ: “Pigtail” catheter drainage in thoracic surgery. Am Rev Respir Dis 1987; 136: 174-175.

12.    Leo F, Solli P, Veronesi G, Spaggiari L, Pastorino U: Efficacy of microdrainage in severe subcutaneous emphysema. Chest 2002; 122:1498-1499.

13.    Ozdogan M, Gurer A, Gokakin AK: Treatment of severe subcutaneous emphysema by fenestrated angiocatheter. Intensive Care Med 2005; 31: 168.

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address:

*Tomasz Kubik
II Klinika Anestezjologii i Intensywnej Terapii
Warszawski Uniwersytet Medyczny
ul. Banacha 1A
02-097 Warszawa
tel.: 22 599 20 02

received: 01.02.2011
accepted: 08.05.2011