|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 3 | Page : 157-158
Demystifying subcutaneous emphysema in intensive care unit
Swati Jindal, Sarabjeet Chhabra
Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
|Date of Submission||19-Sep-2020|
|Date of Acceptance||03-Oct-2020|
|Date of Web Publication||25-Dec-2020|
Dr. Swati Jindal
Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jindal S, Chhabra S. Demystifying subcutaneous emphysema in intensive care unit. Airway 2020;3:157-8
A 50-year-old male presented to the hospital following a road traffic accident with blunt trauma to the chest. On presentation to the emergency department, the patient was haemodynamically stable. However, he had paradoxical respiration with a respiratory rate of 40 breaths/min. There was no history of head injury and upper airway, neck or abdominal trauma. Systemic examination did not reveal any significant findings other than tenderness and crepitus over the chest wall, and bilaterally diminished breath sounds and coarse crepitation on auscultation. A diagnosis of flail chest was made based on the chest X-ray findings of bilateral fracture of the 2nd, 3rd and 4th ribs along with comminuted stable fracture of the sternum. Left-sided pneumothorax and right-sided haemothorax were identified for which bilateral intercostal chest tubes were inserted at the 5th intercostal space and connected to underwater seal systems. Detailed examination revealed subcutaneous emphysema extending from the neck to the lower abdomen. In view of increasing respiratory distress, the patient was intubated with ease under direct laryngoscopy using an 8.0 mm ID cuffed endotracheal tube. The patient was shifted to the intensive care unit (ICU) for elective mechanical ventilation and further management. On arrival in the ICU, an infusion of midazolam and morphine was started for sedation and analgesia. Ventilation with 100% oxygen was done, intercostal tubes were readjusted and bilateral infraclavicular incisions were made to let out the air in the subcutaneous plane. Despite these actions, the subcutaneous emphysema failed to resolve even after 48 h. Repeat chest X-ray revealed presence of air in the subcutaneous tissue with no evidence of pneumothorax and/or haemothorax. Due to the probability of the patient requiring prolonged mechanical ventilation, elective tracheostomy was planned and an ENT surgeon was consulted. Once the incision for tracheostomy was made, a 1 cm rent was seen in the trachea between the 2nd and 3rd tracheal rings. A cuffed tracheostomy tube (8.0 mm ID) was inserted just below the rent, and the rent was allowed to heal spontaneously. Subcutaneous emphysema settled within 48 h of the tracheostomy. The patient was weaned off the ventilator uneventfully over a period of 8 days. He was decannulated using consecutively smaller tracheostomy tubes, and the tracheostomy site closed after 10 days. The patient was stable on follow-up at 7 and 14 days.
Subcutaneous emphysema characterised by air in the subcutaneous tissue planes is usually seen following blunt or penetrating injuries to the chest wall and neck. It may also be seen as a result of trauma created during a difficult intubation or an improperly positioned intercostal chest tube. Although injury to the laryngotracheal anatomy is relatively uncommon (approximately 15%) due to the bony guarding by the mandible, sternum and cervical spine, injuries to the neck often result in subcutaneous emphysema with dire consequences. Injury to the trachea frequently presents clinically as dysphonia, dyspnoea, dysphagia, haemoptysis, pain, mediastinal emphysema, pneumothorax and most commonly subcutaneous emphysema. Large amounts of air can accumulate usually in the supraclavicular spaces with subsequent involvement of the neck and chest wall area.
Diagnosis is primarily by physical findings of crepitus on palpation and confirmed by lateral and posteroanterior chest and neck X-rays. Chest and neck computed tomography scans can also help in confirming the diagnosis with a sensitivity of 85%. However, bronchoscopy remains the main modality to diagnose the precise location and extent of tracheal injury.
As our patient did not have any external evidence of injuries on the neck, tracheal trauma was not suspected. It was thought that the subcutaneous emphysema was due to the underlying pneumothorax. Hence, infraclavicular skin incisions were made and intercostal chest drains were inserted and repositioned to ensure their proper functioning. Due to the lack of clinical recovery despite the various interventions and the chest X-ray showing resolved pneumothorax, a tracheostomy was planned, which led to the diagnosis of the actual pathology.
Although subcutaneous emphysema mostly runs a benign, self-limiting course mandating only conservative management, its persistence even after surgical interventions and negative radiological confirmation should point towards a differential aetiology, as long-standing subcutaneous emphysema can lead to upper airway and jugular venous compression resulting in airway and cardiovascular compromise. A vigilant approach and a high index of suspicion should be maintained for laryngotracheal injuries in patients with severe and persistent subcutaneous emphysema even without the signs of external neck injuries. An emergency tracheostomy seems to be the preferred therapeutic step and a common consensus among clinicians in such situations. As this allows spontaneous healing of the injury by decreasing the intratracheal pressure and air leakage through the tear, it should be undertaken at the earliest.,,, On the other hand, conservative management is practiced in patients with tracheal ruptures of <3 cm with no evidence of sepsis, and an intact tracheal length of more than 3 cm above carinal angle.,
Declaration of patient consent
The authors certify that they have obtained the appropriate patient consent form. In the form, the patient has given his consent for clinical information to be reported in the journal. The patient understands that his name and initial will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Domino KB, Posner KL, Caplan RA, Cheney FW. Airway injury during anaesthesia: A closed claim analysis. Anesthesiology 1999;91:1703-11.
Jewett BS, Shockley WW, Rutledge R. External laryngeal trauma: Analysis of 392 patients. Arch Otolaryngol Head Neck Surgery 1999;125:877-80.
Cicala RS, Kudsk KA, Butts A, Nguyen H, Fabian TC. Initial evaluation and management of upper airway injuries in trauma patients. J Clin Anesth 1991;3:91-8.
Mullan GPJ, Georgalas C, Arora A, Narula A. Conservative management of a major post-intubation tracheal injury and review of current management. Eur Arch Otorhinolaryngol 2007;264:685-8.
Seidl RO, Todt I, Nielitz T, Ernst A. Tracheal ruptures in endotracheal intubation. Diagnosis and therapy. HNO 2002;50:134-8.
Óvári A, Just T, Dommerich S, Hingst V, Böttcher A, Schuldt T, et al
. Conservative management of post-intubation tracheal tears - Report of three cases. J Thorac Dis 2014;6:E85-91.
Boonsarngsuk V, Suwatanapongched T, Korrungruang P, Raweelert P. A patient with subcutaneous emphysema following endotracheal intubation. Respiratory Care 2012;57:1191-4.