What is the management of surgical emphysema?

Management of Surgical Emphysema

Surgical emphysema is typically a self-limiting condition requiring conservative management with close airway monitoring, upright positioning, high-flow humidified oxygen, adequate analgesia, and reassurance—surgical intervention is rarely needed. 1, 2

Initial Assessment and Monitoring

Close observation is mandatory with continuous monitoring of:

• Level of consciousness, respiratory rate, heart rate, blood pressure, oxygen saturation, temperature, and pain score 1, 3
• Capnography using a specially designed facemask to aid early detection of airway obstruction 1, 3
• Never ignore a patient who is agitated or complains of difficulty breathing, even if objective signs are absent 3, 1

Warning signs requiring immediate escalation include:

• Stridor or obstructed breathing pattern 3, 1
• Signs of mediastinitis (severe sore throat, deep cervical pain, chest pain, dysphagia, painful swallowing) 3
• Fever and progressive crepitus 3
• Airway compromise or respiratory distress 4

Conservative Management (First-Line for Stable Patients)

Positioning and Respiratory Support

• Position the patient upright (head of bed elevated 30 degrees or higher) to optimize respiratory mechanics and reduce work of breathing 1, 3
• Administer high-flow humidified oxygen to patients with respiratory compromise 1, 3
• End-tidal carbon dioxide monitoring is desirable to assess ventilation adequacy 1, 3
• Avoid factors that impede venous drainage from the affected area 3, 1

Airway Management Adjuncts

• For patients with obstructive sleep apnea, a nasopharyngeal airway may overcome upper airway obstruction 3, 1
• If the patient uses CPAP at home, ensure it's available for use during recovery and on the ward 3, 1
• Encourage deep breathing and coughing to clear secretions 3, 1

Pain Management

• Adequate analgesia is essential to keep the patient comfortable and facilitate deep breathing 1, 2
• Analgesia prevents secondary complications like restricted breathing and aids mobilization 1
• For severe cases with significant discomfort, consider intrapleural bupivacaine (0.25%) 1

Psychological Support

• Provide a calm atmosphere and reassurance, as anxiety increases work of breathing 1, 3

Pharmacological Considerations

The consensus on antibiotic and corticosteroid therapy remains unclear 2. However:

• Prophylactic antibiotics may be considered occasionally, particularly if there is concern for bacterial translocation through tissue planes 2
• Steroids are rarely indicated but may be considered for inflammatory airway edema from direct airway injury 3

Indications for Intervention

Airway Compromise

If there are any concerns about airway patency, secure the airway definitively with either:

• Endotracheal intubation, or
• Emergency tracheostomy depending on clinical judgment 4

Patients with laryngeal trauma resulting in surgical emphysema have the potential to deteriorate rapidly and require close monitoring in a high-dependency unit setting 4.

Extensive Surgical Emphysema Requiring Decompression

For severe and extensive surgical emphysema marked by:

• Palpable cutaneous tension
• Dysphagia or dysphonia
• Palpebral closure
• Associated pneumoperitoneum
• Airway compromise or "tension phenomenon"
• Respiratory failure 5

Treatment options include:

• Large-bore (26 French) fenestrated subcutaneous drain maintained on low negative pressure (-5 cm H₂O) for 24-48 hours 5
• Multisite subcutaneous drainage 5
• Infraclavicular "blow holes" incisions 5
• Increasing suction on an in situ chest drain if present 5
• Emergency tracheostomy in cases of severe airway compromise 5

Associated Complications

• Bilateral pneumothoraces require bilateral chest drains 4
• Respiratory arrest necessitates intubation and potentially tracheostomy 4

Monitoring Duration and Follow-Up

• Stable patients with no evidence of laryngeal edema can be managed conservatively with close monitoring 4
• Typical observation period is 24 hours for uncomplicated cases 2
• Close monitoring is essential to prevent any potential airway compromise, as patients can deteriorate rapidly 4
• Early mobilization and exercise are recommended as soon as the patient is stable 1

Common Pitfalls to Avoid

• Do not rely solely on pulse oximetry, as it is not designed to monitor ventilation and can give incorrect readings in various circumstances 3
• Advise patients to avoid nose blowing following facial bone fractures or trauma, as this can exacerbate surgical emphysema 2, 6
• Consider tailored advice regarding drug habits (particularly cocaine insufflation) in at-risk patient cohorts, as this can significantly worsen surgical emphysema 2