Pneumomediastinum and surgical emphysema
September 7, 2017 at 7:52 am #69
89 year old man with history of underlying IPF/NSIP on Prednisolone. Admitted with sudden onset surgical emphysema involving face. CT showed significant pneumomediastinum and subcutaneous emphysema, but no pneumothorax. Initially improved with high flow oxygen, but started deteriorating after 10 days. Periarrest with airway compromise. I inserted a large bore drain on the right after blunt dissection. Planned to insert one to left as well, but he was unable to tolerate. Initial bubbling, but drain did not seem to make a difference.
I have spoken to colleagues in North Wales about the case as I have not come across such severe pneumomediastinum/s/c emphysema without a pneumothorax before. Management was challenging. Surgeons advised s/c incisions and even a s/c drains open to air / on suction.
Unfortunately developed HAP and passed away a few days ago.
Has anyone had a similar experience?November 10, 2017 at 11:12 pm #183
I haven’t managed a case of pneumomediastinum in isolation, but we did have a similarly challenging case in Hywel Dda earlier this year. A patient with a recurrent pneumothorax on a background of CTD-ILD developed the most severe subcutaneous emphysema that I have witnessed along with a pneumomediastinum.
My colleague suggested making “blowhole” incisions. We felt that we had little to lose as we encountered difficulty railroading an even larger chest drain over the existing wide-bore tube and evident airway compromise. Two infraclavicular incisions were made around 5cm in length allowing the subcutaneous air to be “massaged” out.
This resulted in a dramatic improvement in the subcutaneous emphysema. It’s an option worth exploring in these extreme situations as it aids in symptomatic relief and drain insertion. Such cases would ideally be managed surgically, but it’s often the case that this isn’t readily available locally or the patient’s condition does not allow for a safe transfer to a surgical centre.
Does anyone else have experience of using infraclavicular incisions to manage severe subcutaneous emphysema?March 8, 2018 at 5:16 pm #281
Severe Pneumomediastinum that causes such a severe surgical emphysema is a rare entity. I have only seen such a severe pneumomediastinum in patients with traumatic rupture of bronchial tree. Normally the most common cause for spontaneous pneumomediastinum is rupture of mediastinal blebs and it normally happens in young patients. Esophageal rupture after vomiting is the second cause.The mediastinal blebs rupture but they are contained so the air is absorbed within days. I think you managed the case very well. I would have done exactly the same. Now regarding the subcutaneous drains, they are very effective. I have placed subcutaneous drains in many occasions with remarkable results. You create a long subcutaneous track, starting from the height of 4-5 rib,anterior to the pectoralis major muscles.You have to use finger dissection,which is quite easy due to the massive surgical emphysema. Normally the tissues will divide very easily and you will have a good plane. Make the track as long as you can. You can even place 2 drains. Always use large drains otherwise the subcutaneous fat will block the drain holes.Some surgeons put the drain on low suction as well. Another interesting and effective technique is the use of vac pumps,the sames we use for wound healing. You make a 4-5 cm incision and you open the subcutaneous space. Then you put the sponge and the vac pump. The negative suction gives similar results to the subcutaneous drains.I think that this case was very challenging and quite rare.March 8, 2018 at 8:34 pm #282
I hadn’t thought of using a vacuum dressing. That’s certainly something to bear in mind!
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