What is the treatment for subcutaneous emphysema?

Treatment of Subcutaneous Emphysema

For most cases of subcutaneous emphysema, treatment is conservative with close observation, oxygen therapy, and management of the underlying cause, but severe cases with respiratory compromise require immediate airway assessment and may need subcutaneous drainage or emergency airway intervention. 1, 2, 3

Initial Assessment and Stabilization

Airway and Breathing Evaluation

• Immediately assess for signs of respiratory distress including stridor, accessory muscle use, tracheal tug, and sternal/subcostal/intercostal recession 1, 3
• Evaluate airway patency through clinical examination and suction if tracheostomy is present 1
• Use waveform capnography when available to detect early airway obstruction 2, 3
• Monitor vital signs continuously including respiratory rate, heart rate, blood pressure, oxygen saturation, and level of consciousness 2

Patient Positioning and Oxygen Therapy

• Position the patient upright with head of bed elevated 30 degrees to optimize respiratory mechanics 2
• Administer high-flow humidified oxygen to the face and tracheostomy (if present) 1, 2, 3
• For patients with obstructive sleep apnea, consider a nasopharyngeal airway to overcome upper airway obstruction 2
• Maintain end-tidal carbon dioxide monitoring to assess ventilation adequacy 2

Psychological Support

• Create a calm atmosphere and provide reassurance, as anxiety increases work of breathing 2
• Never ignore a patient who is agitated or complains of difficulty breathing, even without objective signs 2

Identify and Treat the Underlying Cause

Diagnostic Workup

• Obtain chest radiography to detect pneumothorax, pneumomediastinum, or other thoracic injuries 4, 3
• Consider CT scan with contrast for detailed assessment of injury extent and air collection 3
• Check inflammatory markers (white blood cell count, C-reactive protein) to evaluate for infection 3

Management of Pneumothorax

If pneumothorax is present, insert a small-bore chest tube (10-14F) as there is no evidence that larger tubes (20-24F) are more effective. 4, 3

• Place the tube in the 5th intercostal space, mid-axillary line using strict aseptic technique to minimize infection risk (reported at 1%) 4, 3
• If a chest tube is already in place and subcutaneous emphysema develops, immediately unclamp if clamped, check for kinking or displacement, and ensure proper function 3
• Never clamp a bubbling chest tube as this can convert a simple pneumothorax into life-threatening tension pneumothorax 4, 3

Management of Severe Subcutaneous Emphysema

Conservative Measures

• Encourage deep breathing and coughing to clear secretions 2
• Provide adequate analgesia to keep the patient comfortable and facilitate deep breathing 2
• Consider intrapleural bupivacaine (0.25%) for significant discomfort 2
• Avoid factors that impede venous drainage from the affected area 2
• Early mobilization and exercise once the patient is stable 2

Subcutaneous Drainage for Severe Cases

When subcutaneous emphysema is massive and causing symptoms such as inability to open eyes, dysphonia, dysphagia, or respiratory compromise, subcutaneous drainage is indicated. 5, 6, 7, 8

• Insert fenestrated subcutaneous catheters or 14G subcutaneous cannulas in the anterior chest wall 5, 8
• Apply suction to the subcutaneous drains for effective decompression 7
• Perform confluent centripetal massage toward drainage orifices for immediate improvement 5
• This technique provides rapid symptom resolution and is simple, cost-effective, and minimally invasive 7, 8

Alternative Therapies

• Hyperbaric oxygen therapy has been reported as a treatment option for severe subcutaneous and mediastinal emphysema, though evidence is limited 9

Emergency Airway Management

When Conservative Measures Fail

In situations of severe airway compromise unresponsive to initial measures, emergency intubation following Difficult Airway Society guidelines is required. 1

• Perform cricothyroidotomy with scalpel-bougie-tube technique (preferred over cannula cricothyroidotomy) if unable to intubate or oxygenate 1
• The scalpel-bougie-tube approach reduces gas trapping and maximizes respiratory gas exchange 1
• Emergency tracheostomy may be necessary in extreme cases 1

Warning Signs Requiring Immediate Escalation

• Stridor or obstructed breathing pattern 2
• Severe agitation despite reassurance 2
• Signs of mediastinitis including severe sore throat, deep cervical pain, chest pain, or dysphagia 2
• Progressive subcutaneous emphysema despite treatment 6
• Inability to maintain adequate oxygenation or ventilation 1

Common Pitfalls to Avoid

• Do not attempt ventilation through a displaced tracheostomy tube or into a false passage 3
• Avoid clamping chest tubes that are still bubbling 4, 3
• Do not delay intervention in patients with rapidly progressive subcutaneous emphysema 8
• Ensure proper aseptic technique during any invasive procedure to minimize infection risk 4, 3