How to manage surgical emphysema?

Management of Surgical Emphysema

Surgical emphysema should be managed primarily with reassurance, close observation, and supportive care, as it is typically self-limiting and resolves spontaneously in most cases. 1, 2

Initial Assessment and Management

• A calm atmosphere and reassurance are particularly helpful for patients with surgical emphysema as anxiety increases work of breathing 1
• Close observation is essential, with monitoring of:
  • Level of consciousness
  • Respiratory rate
  • Heart rate
  • Blood pressure
  • Oxygen saturation
  • Temperature
  • Pain score 1
• Capnography using a specially designed facemask can aid early detection of airway obstruction 1
• Position the patient upright (head of bed elevated 30 degrees) to optimize respiratory mechanics and reduce work of breathing 1

Respiratory Support

• Administer high-flow humidified oxygen to patients with respiratory compromise 1
• End-tidal carbon dioxide monitoring is desirable to assess ventilation adequacy 1
• For patients with obstructive sleep apnea, a nasopharyngeal airway may overcome upper airway obstruction 1
• If the patient uses CPAP at home, ensure it's available for use during recovery and on the ward 1
• Avoid factors that would impede venous drainage from the affected area 1
• Encourage deep breathing and coughing to clear secretions 1

Pain Management

• Adequate analgesia is essential to keep the patient comfortable and facilitate deep breathing 1
• Analgesia helps prevent secondary complications like restricted breathing and aids mobilization 1
• For severe cases, consider intrapleural bupivacaine (0.25%) if discomfort is significant 1

Specific Interventions for Extensive Surgical Emphysema

• Most cases are self-limiting and require only observation and supportive care 2, 3
• For severe cases with respiratory compromise, consider:
  • Subcutaneous drainage using a large-bore fenestrated catheter maintained under low suction (-5 cm H2O) 3
  • Infraclavicular "blow holes" incisions for rapid decompression in emergency situations 3
  • Increasing suction on an in-situ chest drain if present 3

Antibiotic Therapy

• Prophylactic antibiotics may be considered if there is concern about infection, particularly with extensive surgical emphysema 2
• Co-amoxiclav is a reasonable choice for prophylaxis when deemed necessary 2
• The consensus on antibiotic therapy remains unclear, and should be based on clinical judgment of infection risk 2

Monitoring and Follow-up

• A patient who is agitated or complains of difficulty breathing should never be ignored, even if objective signs are absent 1
• Warning signs requiring immediate attention include:
  • Stridor
  • Obstructed pattern of breathing
  • Agitation
  • Progressive swelling
  • Signs of mediastinitis (severe sore throat, deep cervical pain, chest pain, dysphagia) 1
• Early mobilization and exercise are recommended as soon as the patient is stable 1

Special Considerations

• For post-traumatic surgical emphysema, advise patients to avoid activities that increase pressure in air spaces (nose blowing, Valsalva maneuvers) 2, 4
• For patients with substance use disorders, specifically advise against intranasal drug use, which can significantly exacerbate surgical emphysema 2
• In cases associated with pneumothorax, ensure proper chest drain management 3, 5
• For surgical emphysema following dental procedures or facial trauma, close monitoring of the airway is essential 2

Disposition

• Patients with mild to moderate surgical emphysema can often be managed as outpatients with appropriate follow-up 2
• Those with extensive surgical emphysema, respiratory compromise, or underlying significant pathology require inpatient observation until improvement is demonstrated 3, 5