What is the management approach for emphysematous air in the ventricles?

Management of Emphysematous Air in Ventilated Patients

Immediately obtain a chest X-ray to identify pneumothorax, pneumomediastinum, and the extent of subcutaneous emphysema, as these complications require urgent intervention to prevent catastrophic deterioration. 1

Immediate Assessment and Diagnosis

When emphysematous air (subcutaneous emphysema, pneumomediastinum, or pneumothorax) develops in a ventilated patient, this represents a critical airway emergency requiring systematic evaluation:

• Verify endotracheal tube position immediately by checking bilateral chest wall expansion, as auscultation is unreliable in critically ill patients wearing PPE or in noisy ICU environments 2, 1
• Obtain urgent chest X-ray to confirm tube depth, identify pneumothorax, assess pneumomediastinum extent, and rule out inadvertent endobronchial intubation 1
• Perform lung ultrasound if there is any doubt about bilateral lung ventilation or pneumothorax, as it is superior to auscultation for detecting pneumothorax in intubated patients 1
• Check and document endotracheal tube depth at the teeth/lips, as difficult laryngoscopy is associated with inadvertent endobronchial intubation and traumatic intubation can cause air leak 2

Ventilator Management

The cornerstone of managing emphysematous air involves immediate ventilator adjustments to prevent worsening barotrauma:

• Reduce peak inspiratory pressures to the minimum levels consistent with adequate oxygenation and ventilation 1
• Minimize positive end-expiratory pressure (PEEP) while maintaining acceptable oxygen saturation 1
• Verify endotracheal tube cuff pressure is maintained at 20-30 cmH2O to prevent air leak around the cuff, which can worsen subcutaneous emphysema 2, 1
• Consider permissive hypercapnia if the patient can tolerate mild hypoventilation, as this reduces the risk of further barotrauma 2

A critical pitfall: bronchial intubation with the endotracheal tube cuff positioned too distally can cause localized barotrauma and should be immediately corrected 1.

Ruling Out Pneumothorax

Pneumothorax is the most life-threatening cause of emphysematous air and must be addressed emergently:

• Use the DOPE mnemonic (tube Displacement, tube Obstruction, Pneumothorax, Equipment failure) when any intubated patient deteriorates acutely 2
• Insert a chest tube immediately if tension pneumothorax is suspected based on hemodynamic instability, severe respiratory distress, or unilateral absent breath sounds 2
• Perform fibreoptic bronchoscopy if there is concern for tracheal injury, as traumatic intubation can cause pharyngeal or oesophageal injury leading to deep infection and life-threatening sepsis 2

Avoiding Further Complications

Several interventions can worsen emphysematous air and must be avoided:

• Do NOT use oxygen insufflation through airway exchange catheters except in extremis, as even low-flow oxygen administration via an airway exchange catheter risks catastrophic barotrauma if the catheter tip is placed or migrates beyond the carina 2, 1
• Avoid repeated intubation attempts in patients with suspected tracheal injury, as this increases trauma and worsens perforation 1
• Do NOT perform transtracheal jet ventilation (TTJV) if front-of-neck access is needed, as subcutaneous emphysema hinders later open approaches and TTJV is associated with high rates of barotrauma 2

Monitoring and Ongoing Management

Once initial stabilization is achieved:

• Maintain humidification and regular tracheal suction using closed suction systems to reduce tube blockage and minimize aerosol generation 2, 3
• Check cuff pressure and tube depth before and after any patient repositioning, including prone positioning, turning, nasogastric tube placement, or tracheal suction 2, 3
• Monitor for signs of infection including fever, as pharyngeal or oesophageal injury may lead to mediastinitis requiring antibiotics 2
• Observe for progression of surgical emphysema, bleeding, and swelling if the airway has been traumatized 2

When Surgical Consultation is Needed

Most cases of subcutaneous emphysema in ventilated patients resolve with conservative management once the underlying cause is addressed. However, surgical consultation is warranted if:

• Persistent air leak despite optimal ventilator management suggests major airway injury 2
• Progressive pneumomediastinum with hemodynamic compromise requires thoracic surgery evaluation 4
• Suspected tracheal perforation from traumatic intubation needs urgent surgical assessment 2

The evidence strongly supports that spontaneous pneumomediastinum with subcutaneous emphysema is typically self-limiting and benign when managed conservatively with rest, oxygen, and observation 4. However, the presence of these findings in a mechanically ventilated patient suggests iatrogenic barotrauma requiring the systematic approach outlined above.