What is the management plan for subcutaneous (subcut) emphysema after lobar resection?

Management of Subcutaneous Emphysema After Lobar Resection

For patients with subcutaneous emphysema after lobar resection, initial management should focus on maximizing chest tube suction, but for recalcitrant cases, video-assisted thoracoscopic surgery (VATS) with pneumolysis is recommended as the most effective intervention to resolve symptoms and reduce hospital stay. 1

Initial Assessment and Conservative Management

• Subcutaneous emphysema occurs in approximately 6.3% of patients following pulmonary resection and is more common in patients with preoperative FEV1% less than 50%, those with air leaks, and patients who have had previous thoracotomy 1
• Initial management should include:
  • Ensuring chest tube patency and optimizing drainage position 1
  • Maximizing chest tube suction to direct air leakage into the pleural space rather than subcutaneous tissues 1
  • Close monitoring for respiratory or cardiovascular compromise, particularly when emphysema extends to the neck region 2

Management of Recalcitrant Subcutaneous Emphysema

Approximately one-third of patients (33%) will develop recalcitrant subcutaneous emphysema despite maximized chest tube suction 1. These patients require more aggressive intervention:

First-Line Intervention for Recalcitrant Cases:

• Single-incision VATS with pneumolysis and chest tube placement is highly effective, resolving subcutaneous emphysema within 24 hours in nearly all patients 1
• This procedure works by releasing adhesions between the leaking lung and the previously opened intercostal space, redirecting air leak back into the pleural space 1
• Patients treated with this approach have significantly shorter hospital stays (6 vs 9 days) compared to those managed with other approaches 1

Alternative Interventions:

• Subcutaneous drain placement can provide symptomatic relief for patients with extensive subcutaneous emphysema causing dysphonia or dysphagia 2
• Negative pressure wound therapy dressings have been reported as an effective treatment option in case reports 3
• Hyperbaric oxygen therapy has been described in limited case reports but is not considered standard practice 4

Risk Factors and Monitoring

• Patients at higher risk for developing recalcitrant subcutaneous emphysema include:

  • Those with lower FEV1% 1
  • Patients who have undergone previous ipsilateral thoracotomy 1
  • Those who have undergone lobectomy rather than sublobar resection 1

• Careful monitoring should include:

  • Regular chest radiographs to assess for pneumothorax development, including on the contralateral side 5
  • Assessment for signs of airway compromise if emphysema extends to the neck region 2
  • Monitoring for tension pneumothorax, which can develop after initial chest drain removal 2

Special Considerations

• In rare cases, subcutaneous emphysema may be accompanied by contralateral pneumothorax, which requires prompt recognition and chest tube drainage 5
• Follow-up radiographic examinations should be performed within a few hours after initial presentation of subcutaneous emphysema to monitor for progression 5
• Patients with COPD may be at higher risk for developing extensive subcutaneous emphysema and may require more aggressive management 2