What is the management plan for a patient with subcutaneous emphysema at incision sites following a recent thoracic or abdominal surgical procedure?

Management of Subcutaneous Emphysema at Incision Sites

Immediate Assessment

For subcutaneous emphysema at surgical incision sites following thoracic or abdominal procedures, immediately assess for respiratory compromise and identify the underlying cause—most commonly pneumothorax or air leak from the surgical site. 1, 2

Critical Initial Steps

• Check for signs of respiratory distress including stridor, accessory muscle use, tracheal tug, and intercostal retractions—these indicate potential airway compromise requiring urgent intervention 1, 2
• Provide high-flow oxygen immediately while completing your assessment 1
• Palpate for crepitus to determine the extent and progression of subcutaneous emphysema 1
• Examine any existing chest tubes or drains for patency, kinking, or displacement if present 1

Diagnostic Workup

• Obtain chest radiography immediately to detect pneumothorax, pneumomediastinum, or other thoracic injuries 1, 2
• Consider CT scan with contrast for detailed assessment if the clinical picture is unclear or extensive air tracking is suspected 1, 2
• Check inflammatory markers (white blood cell count, C-reactive protein) to evaluate for potential infection at the incision site 1, 2

Treatment Algorithm

If Chest Tube Already Present

• Immediately unclamp the tube if it was clamped—clamping a bubbling chest tube can convert a simple pneumothorax into life-threatening tension pneumothorax 1, 2
• Check tube patency by ensuring no kinking, proper positioning, and secure connection to drainage system 1
• Verify the tube is functioning and bubbling appropriately 1

If No Chest Tube Present and Pneumothorax Detected

• Insert a small-bore chest tube (10-14F) in the 5th intercostal space, mid-axillary line—there is no evidence that larger tubes (20-24F) are more effective 1, 2
• Use strict aseptic technique to minimize infection risk (reported at 1%) 1, 2

For Extensive Subcutaneous Emphysema Without Airway Compromise

• Consider subcutaneous drain placement if the emphysema is causing significant discomfort or tension but no respiratory compromise 3, 4, 5
• Use a large-bore (26 French) fenestrated catheter inserted subcutaneously in the affected area 3
• Maintain low suction (-5 cm H2O) for 24-48 hours 3, 4
• Alternative approach: Insert 14G subcutaneous cannulas in the anterior chest wall for rapid decompression 5

For Severe Cases With Airway Compromise

• Perform emergency intubation following Difficult Airway Society guidelines if severe airway compromise develops 2
• Prepare for cricothyroidotomy using scalpel-bougie-tube technique if unable to intubate or oxygenate 2

Ongoing Management

• Monitor respiratory status continuously including oxygen saturation, respiratory rate, and progression of subcutaneous emphysema 1, 2
• Continue oxygen therapy based on saturation levels 1
• Treat the underlying cause (pneumothorax, air leak from incision) definitively 1
• Avoid routine subcutaneous drains at the incision site for prophylaxis—they provide no advantage in preventing wound infection 6, 7

Warning Signs Requiring Immediate Escalation

• Severe sore throat, deep cervical pain, chest pain, or dysphagia—these may indicate mediastinitis requiring urgent intervention 2
• Dysphonia or dysphagia—suggests air tracking into the neck with potential airway compromise 4, 5
• Palpebral closure from facial swelling—indicates extensive air tracking requiring aggressive management 3, 8
• Inability to maintain adequate oxygenation—requires immediate airway protection 2

Critical Pitfalls to Avoid

• Never clamp a bubbling chest tube—this is the most dangerous error and can create tension pneumothorax 1, 2
• Do not delay intervention in rapidly progressive cases—subcutaneous emphysema can progress from minimal to life-threatening within 30 minutes 8
• Do not place prophylactic subcutaneous drains at the surgical incision for infection prevention—evidence shows no benefit 6, 7
• Do not assume self-limitation—while most cases resolve spontaneously, delayed presentations can rapidly deteriorate 8

Incision-Specific Considerations

For contaminated or dirty incisions with subcutaneous emphysema, consider delayed primary closure rather than immediate closure to reduce surgical site infection risk, with revision planned between 2-5 days postoperatively 6, 7