How to manage subcutaneous air (subcutaneous emphysema) following a pneumothorax?

From the Guidelines

The primary approach to managing subcutaneous air after a pneumothorax involves ensuring adequate chest tube drainage and monitoring the air in the tissues, with most cases resolving spontaneously within 5-7 days without specific intervention for the subcutaneous emphysema itself. This approach is based on the principle of treating the underlying cause of the subcutaneous emphysema, which is the pneumothorax, and allowing the body to absorb the air that has leaked into the subcutaneous tissues. The use of supplemental oxygen (2-4 L/min via nasal cannula) can enhance the resolution of subcutaneous air by creating a pressure gradient that facilitates nitrogen washout from the tissues 1.

Key Considerations in Management

• Ensuring proper placement and function of the chest tube is crucial, as a malpositioned, kinked, blocked, or clamped tube can exacerbate subcutaneous emphysema 1.
• The chest tube should be connected to suction at an appropriate level, typically -20 cm H2O, to facilitate the evacuation of air from the pleural space and reduce the likelihood of air leaking into the subcutaneous tissues.
• If subcutaneous emphysema is extensive or progressive, consideration should be given to placing a second chest tube or repositioning the existing one to improve drainage and reduce the air leak 1.
• Pain management is important, with acetaminophen or NSAIDs being appropriate for most cases, and opioids reserved for severe discomfort.
• Reassurance is crucial, as the symptoms of subcutaneous emphysema can be distressing for patients.

Intervention for Severe Cases

For severe cases of subcutaneous emphysema that cause significant discomfort or functional impairment, additional interventions may be considered, such as the placement of subcutaneous drains or microdrainage catheters. However, these interventions should be reserved for cases where conservative management is insufficient, as they carry their own risks and complications 1. Surgical intervention is rarely needed and is typically considered only in cases of persistent air leak from the underlying pneumothorax that does not resolve with conservative management.

From the Research

Management of Subcutaneous Air after Pneumothorax

Subcutaneous emphysema (SE) is a condition where air occupies structures under the skin and soft tissues, often occurring after a pneumothorax. The management of SE is crucial to prevent further complications.

• Supportive Care: Supportive care is a common method of treatment for SE, which includes monitoring the patient's condition and providing oxygen therapy as needed 2.
• Placement of Blow Holes: Placement of blow holes for evacuation of soft-tissue emphysema is another method of treatment, which can help to remove the air trapped under the skin 2.
• Bilateral Infraclavicular Incisions: Bilateral infraclavicular incisions can also be used to manage SE, especially in cases where the air is trapped in the deeper tissues of the thoracic outlet, chest, and abdominal wall 2.
• Chest Tube Therapy: Conventional chest tube therapy can be an effective treatment for iatrogenic pneumothorax, which can help to resolve the SE 3.
• Monitoring and Observation: Patients with SE should be monitored closely for signs of airway compromise, and provided with IV antibiotics and hydration as needed 4.

Diagnosis and Treatment Approach

The diagnosis of SE can be made by detecting edema and crepitus of the scalp, neck, thorax, abdomen, and other body regions, and confirmed by radiograph imaging 2. The treatment approach for SE should be individualized based on the severity of the condition and the underlying cause. In some cases, conservative management may be sufficient, while in other cases, more invasive procedures may be necessary 5, 6.

• Conservative Management: Conservative management can be used for patients with mild SE, which includes supportive care and monitoring 4.
• Invasive Procedures: Invasive procedures, such as chest tube therapy or surgical intervention, may be necessary for patients with severe SE or those who do not respond to conservative management 3.