Is subcutaneous emphysema, especially in the context of a tracheostomy (tracheal tube insertion) and mechanical ventilation, considered a medical emergency?

Subcutaneous Emphysema in Tracheostomy Patients: A Potential Medical Emergency

Subcutaneous emphysema in the context of tracheostomy and mechanical ventilation is a serious complication that should be treated as a medical emergency, as it may indicate a false passage or tube displacement that can rapidly compromise the airway and lead to significant morbidity or mortality. 1

Understanding Subcutaneous Emphysema in Tracheostomy Patients

Subcutaneous emphysema occurs when air enters the tissues beneath the skin, often presenting as swelling and crepitus in the neck and chest. In tracheostomy patients, this complication can arise from:

• False passage of the tracheostomy tube into surrounding tissues
• Partial displacement of the tube
• Excessive airway pressures during ventilation
• Tracheal wall injuries during tube insertion or manipulation

Clinical Significance

The presence of subcutaneous emphysema in a tracheostomy patient is particularly concerning because:

1. It indicates potential tube misplacement that can compromise the airway
2. It may rapidly progress to involve the face, chest, and even the entire body
3. It can be associated with pneumothorax, pneumomediastinum, or pneumoperitoneum in severe cases 2
4. It may signal a life-threatening emergency requiring immediate intervention

Assessment and Management Algorithm

Immediate Assessment

1. Evaluate respiratory status (oxygen saturation, work of breathing, respiratory rate)
2. Assess tracheostomy tube position and patency
   • Check if a suction catheter passes easily through the tube
   • Do not attempt ventilation if the suction catheter will not pass, as this significantly increases the risk of worsening subcutaneous emphysema 1

Emergency Management Steps

If Subcutaneous Emphysema is Detected:

1. Call for expert help immediately - Anesthesia, ENT, or critical care specialists

2. Assess tube position:

   • If tube displacement is suspected, perform an emergency tube change following these steps:
     • First attempt: Same size tube with obturator
     • Second attempt: Half-size smaller tube if first attempt fails
     • Third attempt: Half-size smaller tube with suction catheter guide if needed 1
   • Confirm correct placement after each attempt

3. If the tube is in correct position but subcutaneous emphysema is worsening:

   • Reduce ventilator pressures if on mechanical ventilation
   • Consider changing to a non-fenestrated tube if a fenestrated one is in use 3
   • Administer bronchodilators if bronchospasm is present 3

4. For severe or progressive subcutaneous emphysema:

   • Consider subcutaneous drains with suction as a management option 4
   • Obtain urgent imaging (chest X-ray or CT) to assess for pneumothorax
   • Prepare for possible chest tube insertion if pneumothorax is present 5

Critical Pitfalls to Avoid

1. Never attempt ventilation through a tracheostomy tube if a suction catheter cannot pass freely - This can force more air into tissues and worsen subcutaneous emphysema 1

2. Do not delay seeking expert help - Subcutaneous emphysema can rapidly progress to compromise the airway and cause respiratory failure

3. Do not overlook the possibility of pneumothorax - Subcutaneous emphysema can be associated with pneumothorax, which requires immediate decompression 2, 5

4. Avoid high ventilator pressures - High airway pressures can exacerbate air leakage into tissues 3

Prevention Strategies

• Regular assessment of tracheostomy tube position
• Proper humidification to prevent secretion accumulation 6
• Regular cleaning or replacement of inner cannulas 6
• Continuous monitoring of oxygen saturation in tracheostomy patients 6
• Use of bronchoscopic guidance during percutaneous tracheostomy procedures 5

Subcutaneous emphysema in tracheostomy patients represents a critical warning sign that requires immediate attention and intervention. Prompt recognition and management are essential to prevent progression to life-threatening complications.