What is the severity of worsening subcutaneous emphysema in a patient with an oxygen saturation (SpO2) of 100% on 4 liters per minute (L/min) of oxygen (O2) after chest tube removal?

From the Guidelines

This is a serious condition that requires immediate medical attention, as the worsening subcutaneous emphysema extending to the neck and face, despite good oxygen saturation, suggests air is continuing to leak from the lung or airways into the soft tissues. The patient's current oxygen saturation of 100% on 4L O2 is within the target range, but the increasing subcutaneous emphysema is a cause for concern, as it can rapidly progress and potentially compromise the airway, especially when involving the neck and face 1. The medical team should assess for signs of respiratory distress, voice changes, or difficulty swallowing, and prepare for possible chest tube reinsertion. Immediate interventions should include a stat chest X-ray or CT scan to assess for pneumothorax, close monitoring of respiratory status, and evaluation by a thoracic surgeon or pulmonologist, as progressive subcutaneous emphysema can lead to serious complications including airway compromise, tension pneumothorax, or mediastinal emphysema 1. Some key points to consider in the management of this patient include:

• The requirement for an increased concentration of oxygen is an indication for urgent clinical reassessment of the patient 1
• Patients who have a target saturation of 88–92% should have their blood gases measured within 30–60 min to ensure that the carbon dioxide level is not rising 1
• Stable patients on oxygen treatment should have SpO2 and physiological variables measured four times a day 1
• Oxygen therapy should be increased if the saturation is below the desired range and decreased if the saturation is above the desired range 1
• The underlying cause of the air leak must be identified and addressed, and treatment may require placement of a new chest tube, possibly in a different location than the original, to evacuate the air 1.

From the Research

Condition Overview

• The patient's condition, characterized by increased and worsening subcutaneous emphysema up her neck and face after chest tube removal, is a serious concern.
• Subcutaneous emphysema is a condition where air leaks into the tissues under the skin, which can be a complication of chest tube removal or other lung injuries.

Severity and Prognosis

• The severity of the condition depends on the extent of the subcutaneous emphysema and the patient's overall respiratory status.
• A study on non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS found that non-invasive strategies appear safe and effective in mild-to-moderate hypoxemia 2.
• However, the patient's condition, with Spo2 of 100% on 4L O2, may not be directly related to the studies on hypoxemic respiratory failure and ARDS.

Monitoring and Management

• Close monitoring of the patient's respiratory status, including oxygen saturation and respiratory rate, is crucial in managing the condition.
• A study on the role of SpO2/FiO2 as a non-invasive prognostic marker for intensive care patients with COVID-19 found that a decrease in SpO2/FiO2 is associated with increased mortality risk 3.
• However, the patient's current Spo2 of 100% on 4L O2 does not indicate hypoxemia, and the study's findings may not be directly applicable to this case.

Treatment Options

• The treatment options for subcutaneous emphysema depend on the underlying cause and severity of the condition.
• A study on apnoeic oxygenation during intubation in the intensive care unit found that apnoeic oxygenation reduces patient hypoxaemia during intubation performed in the ICU 4.
• However, the patient's current condition does not necessarily require intubation, and the study's findings may not be directly relevant to this case.

Conclusion is not allowed, and the response should not include any personal opinions or advice.

• The patient's condition should be closely monitored, and treatment options should be considered based on the underlying cause and severity of the subcutaneous emphysema.
• Further studies, such as 5 and 6, may provide additional insights into the management of respiratory failure and the use of non-invasive monitoring tools, but their relevance to this specific case is limited.