Management of Extensive Subcutaneous Emphysema with Vacuum Drainage, without Closed Thoracostomy

Article information

Trauma Image Proced. 2017;2(1):29-31

Publication date (electronic) : 2017 May 31

doi : https://doi.org/10.24184/tip.2017.2.1.29

Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea

Correspondence to: Yang Bin Jeon, Department of Trauma Surgery, Gachon University, Gil Medical Center, 21, 774 beon-gil, Namdongdaero, Namdong-gu, Incheon 21565, Korea Tel: 82-51-240-7369, Fax: 82-51-240-7719, E-mail: junyb@gilhospital.com

Received 2017 March 2; Revised 2017 March 16; Accepted 2017 April 3.

Abstract

A 77-year-old man presented with extensive subcutaneous emphysema and severe dyspnea. We were not able to perform closed thoracostomy because of severe pleural adhesions. Therefore, we treated the subcutaneous emphysema successfully with closed vacuum drainage.

Keywords: Subcutaneous Emphysema; Tissue Adhesions; Pleura

CASE

A 77-year-old man presented with extensive subcutaneous emphysema and severe dyspnea. He had multiple traumatic rib fractures, extensive subcutaneous emphysema, pneumomediastinum, and pneumothorax in the left hemithorax (Fig. 1.). He had a past medical history of coronary artery bypass, chemotherapy for lung cancer, stent insertion for thoracoabdominal aortic aneurysm, balloon dilatation for peripheral vascular disease, heart failure, and diabetic nephropathy. We were not able to perform closed thoracostomy because of severe pleural adhesions (Fig. 1.). However, we had to remove the subcutaneous emphysema because of the patient’s severe dyspnea and poor general condition. Therefore, we choose closed vacuum drainage. The upper part of the previous sternotomy wound was incised and vacuum drainage was applied (Fig. 2.). The vacuum drainage system was removed from the patient because the subcutaneous emphysema had almost resolved (Fig. 3.). There was no recurrence of the subcutaneous emphysema and pneumothorax 1 day later.

Fig. 1.

Axial view of a CT scan of the chest shows multiple rib fractures, extensive subcutaneous emphysema, pneumomediastinum, and pneumothorax in the left hemithorax.

Fig. 2.

(A) Applied vacuum drainage. (B) Sterile polyurethane foam and adhesive drape. (C) Electronic vacuum pump.

Fig. 3.

(A) Chest anteroposterior view radiograph shows extensive subcutaneous emphysema. (B) After 2days, chest anteroposterior view radiograph shows decreased subcutaneous emphysema.

DISCUSSION

Though self-limiting, subcutaneous emphysema should be treated when it causes palpebral closure, dyspnea, dysphagia, or undue disfigurement [1]. Massive accumulated air can compress the trachea and great vessels, which can severely compromise the airway, venous return, and blood flow to the head and neck [2]. After alveolar rupture, air preferentially moves from the pulmonary interstitium along the bronchovascular sheaths to the lung hilum from where it can pass superficial to the endobronchial fascia towards the thoracic inlet. Therefore, the best site for decompressing subcutaneous emphysema is at the level of the thoracic inlet [1]. The key to successful vacuum therapy is sufficient dissection of the prepectoral fascial plane for aspiration of trapped subcutaneous air [2]. The initial treatment for extensive subcutaneous emphysema is closed thoracostomy [1,2]. However, in our case, we could not perform closed thoracostomy, so we applied vacuum drainage to successfully manage the subcutaneous emphysema.

Notes

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

1. Ahmed Z, Patel P, Singh S, Sharma RG, Somani P, Gouri AR, et al. High negative pressure subcutaneous suction drain for managing debilitating subcutaneous emphysema secondary to tube thoracostomy for an iatrogenic post computed tomography guided transthoracic needle biopsy pneumothorax: Case report and review of literature. International Journal of Surgery Case Reports 2016;26:138–41.

2. Byun CS, Choi JH, Hwang JJ, Kim DH, Cho HM, Seok JP. Vacuum-assisted closure therapy as an alternative treatment of subcutaneous emphysema. The Korean journal of thoracic and cardiovascular surgery 2013;46(5):383–7.

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