The Management of Subcutaneous Emphysema in Pneumothorax: A Literature Review

Subcutaneous emphysema in patients undergoing robotic cardiac surgery: risk factors and clinical outcome

Little is known about the incidence of subcutaneous emphysema (SE) after robotic cardiac surgery. The aim of this study was to describe the incidence, identify risk factors, and assess its influence on postoperative outcomes. Patients undergoing robotic mitral valve repair (n = 63, 54.3%), robotic minimally invasive direct coronary artery bypass grafting (n = 23, 19.8%), and robotic totally endoscopic coronary artery bypass grafting (n = 30,25.9%) were included in the analysis (total n = 116). Subcutaneous emphysema occurred in 53/116 patients (45.7%). It was mild in 30/53 patients (56.6%), moderate in one patient (1.9%), and severe in 22/53 patients (41.5%). Low body weight (p = 0.009), low BMI (p = 0.006), small body surface area (p = 0.01), and older age (p = 0.041) significantly correlated with SE. Patients undergoing robotic mitral valve repair were affected more often than patients undergoing robotic coronary artery bypass grafting (p = 0.04). Severe subcutaneous emphysema resulted in an increased need for CT-chest imaging (p = 0.026), and additional chest tubes (p = 0.029). Severe emphysema was highly associated with pneumothorax (p < 0.001) and increased duration of chest tube drainage (p = 0.003). Subcutaneous emphysema after robotic heart surgery occurs preferentially in patients with low body weight, low BMI, a small body surface area, and older age and is more common in robotic MVR than in robotic coronary artery bypass surgery. It leads to an increased need for thoracic imaging and additional chest tube insertion. Clinical outcomes are not affected.

The clinical application of incisional negative pressure wound therapy in severe subcutaneous emphysema: A case series

Severe subcutaneous emphysema (SSE) is the presence of a high-volume accumulation of air in the subcutaneous tissue caused by traumatic injuries, infections, iatrogenic causes, or can also manifest spontaneously. A variety of techniques have been reported, with varying levels of success. We present a multicenter case series detailing four patients who developed SSE and were treated with Incisional Negative Pressure Wound Therapy (INPWT). All patients significantly improved with the INPWT treatment within 6 to 48 h. Our experience suggests INPWT is a valuable procedure available for treating SSE and recommend prospective randomized studies be conducted to determine targeted patient selection and clinical application of INPWT among the SSE patient population.

Tracheostomy Complications: Insights from a Two-Year, 15-Case Analysis at a Tertiary Care Facility

The objective of this case series was to analyse the complications that arise from tracheostomy procedures conducted in a tertiary healthcare facility throughout a two-year timeframe. Fifteen occurrences of complications were observed out of the 100 tracheostomies that were studied, suggesting a prevalence rate of 15%. The detected complications included subcutaneous emphysema, misplacement of the tube, infection at the surgical site, and tracheal stenosis, among various others. Considerable indications of complication were identified, encompassing variables such as age and a history of head and neck cancer. The findings of this study highlight the significance of personalized patient care, vigilant monitoring, and proactive measures for individuals receiving tracheostomy. Further investigations are necessary to validate these findings and improve patient safety and outcomes in the realm of tracheostomy surgeries.

Neonatal Subcutaneous Emphysema Secondary to Chest Tube Placement Using the Trocar Technique: A Case Report

Subcutaneous emphysema is a type of air leak in which air accumulates within the subcutaneous layer of the skin underneath the dermal layers. The accumulation of air can be seen on imaging in relevant body areas such as the abdomen, chest, face, or neck. During physical examination, crepitus, the sensation or sound of crackling upon palpation, is the most common associated finding. Various causes for subcutaneous emphysema exist, with one such cause being thoracostomy or chest tube placement. The trocar technique, in particular, has been associated with greater complications when compared to other techniques. Here, we present a case of subcutaneous emphysema in a neonate occurring after placement of a chest tube using the trocar technique. At this time, much of the knowledge regarding subcutaneous emphysema related to chest tube placement is in the adult population. Clinicians should be aware of this complication in neonates as the body of knowledge regarding this topic continues to grow.

Can sub-cutaneous drain safely counter debilitating surgical emphysema? A retrospective study in quest for an answer

Literature evidence on sub-cutaneous drain insertion in severe surgical emphysema (SE) is lacking. We retrospectively reviewed the clinical notes of 5 patients who underwent insertion of sub-cutaneous drains to manage SE of various aetiologies between September 2022 to August 2023 in a single district general hospital in the UK. Case history, outcome following sub-cutaneous drain insertion, and side effects due to the procedure were collected. Clinical decompression were noticed within an hour of drain insertion in all patients. Radiological resolution ranged between 2 and 10 days with a median 3 days and mean of 4.8 days. Patients with uni-lateral sub-cutaneous drain required more time for radiological improvement than patients on bi-lateral drains (median 6.5 vs. 2, mean 6.5 vs. 3.6). Maximum duration for resolution was 10 days for patients receiving uni-lateral sub-cutaneous drain versus 7 days in patients having bi-lateral drains. Only one patient had no prior lung disease making it difficult to comment if having healthy lungs affects outcomes. Sub-cutaneous drain insertion is a safe procedure which can accelerate recovery in severe SE.

Decompression Technique Using Subcutaneous Angiocatheter Insertion to Relieve Extensive Subcutaneous Emphysema: A Case Report

BACKGROUND

Trauma, pneumothorax, complication of surgery, infection, or malignancy can cause subcutaneous emphysema and although most subcutaneous emphysema cases are self-limited, extensive subcutaneous emphysema can lead to a compromised airway and cardiovascular system. In this report, we described a successful treatment strategy in which subcutaneous angiocatheter insertion was used to relieve the pressure of extensive subcutaneous emphysema.

CASE REPORT

An 83-year-old man was received at the emergency department (ED) for recurrent pneumothorax and extensive subcutaneous emphysema. Six 18-gauge angiocatheters were inserted under the thoracic subcutaneous tissue and a noticeable improvement was seen 3 h after angiocatheter insertion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Subcutaneous angiocatheter insertion may be a safe and uncomplicated decompression technique to relieve extensive subcutaneous emphysema, particularly in the ED.

Pneumomediastinum in COVID-19: a phenotype of severe COVID-19 pneumonitis? The results of the United Kingdom (POETIC) survey

BACKGROUND

There is an emerging understanding that coronavirus disease 2019 (COVID-19) is associated with increased incidence of pneumomediastinum. We aimed to determine its incidence among patients hospitalised with COVID-19 in the United Kingdom and describe factors associated with outcome.

METHODS

A structured survey of pneumomediastinum and its incidence was conducted from September 2020 to February 2021. United Kingdom-wide participation was solicited via respiratory research networks. Identified patients had SARS-CoV-2 infection and radiologically proven pneumomediastinum. The primary outcomes were to determine incidence of pneumomediastinum in COVID-19 and to investigate risk factors associated with patient mortality.

RESULTS

377 cases of pneumomediastinum in COVID-19 were identified from 58 484 inpatients with COVID-19 at 53 hospitals during the study period, giving an incidence of 0.64%. Overall 120-day mortality in COVID-19 pneumomediastinum was 195/377 (51.7%). Pneumomediastinum in COVID-19 was associated with high rates of mechanical ventilation. 172/377 patients (45.6%) were mechanically ventilated at the point of diagnosis. Mechanical ventilation was the most important predictor of mortality in COVID-19 pneumomediastinum at the time of diagnosis and thereafter (p<0.001) along with increasing age (p<0.01) and diabetes mellitus (p=0.08). Switching patients from continuous positive airways pressure support to oxygen or high flow nasal oxygen after the diagnosis of pneumomediastinum was not associated with difference in mortality.

CONCLUSIONS

Pneumomediastinum appears to be a marker of severe COVID-19 pneumonitis. The majority of patients in whom pneumomediastinum was identified had not been mechanically ventilated at the point of diagnosis.

Extensive subcutaneous emphysema from scalp to lower limbs in a 44-year old

A 44-year-old man was admitted after being found suspended by his ankles from a bridge for 5 days. The events leading to it was not clearly known initially. On examination, the patient was hypotensive and hypothermic, airway was oedematous and both lower limbs were mottled with dusky feet. Both foot pulses were impalpable, with prolonged capillary refill time and sensation barely present. Doppler signals were not heard in the feet, but groin pulses and popliteal signals were present. On CT, the patient had bilateral pneumothoraxes, extensive subcutaneous emphysema throughout the body from the subcutaneous tissue of the scalp to both lower limbs and pneumomediastinum and pneumoperitoneum. CT angiogram showed opacification up to proximal crural vessels and absence beyond. After multispeciality input and optimisation of his physiology, he underwent bilateral below knee amputations as they were non-salvageable.