Management of Infraclavicular Blowhole Incisions for Subcutaneous Emphysema
Infraclavicular blowhole incisions should NOT be used as first-line treatment for subcutaneous emphysema following thoracic or abdominal surgery. 1, 2 Conservative management is appropriate for most cases, with blowhole incisions reserved only for life-threatening situations when other interventions have failed.
Initial Assessment and Conservative Management
Most subcutaneous emphysema is benign and self-limiting, resolving within days without intervention. 3, 1, 4
Immediate Actions Required:
- Assess for respiratory compromise including stridor, accessory muscle use, tracheal tug, and intercostal retractions 1
- Provide high-flow oxygen immediately 1
- If a chest tube is present and clamped, IMMEDIATELY unclamp it - clamping a bubbling chest tube can convert simple pneumothorax into life-threatening tension pneumothorax 3, 1, 4, 5
- Check existing chest tubes for patency, kinking, or malposition 1, 4
- Obtain chest radiography to detect pneumothorax or pneumomediastinum 1
First-Line Interventions (Before Considering Incisions):
- Increase suction on existing chest tube - this provides rapid relief in 66-98% of cases following pulmonary resection 2
- Insert a small-bore chest tube (10-14F) if pneumothorax is present without existing drainage 3, 1
- Continue oxygen therapy and monitor respiratory status continuously 1
Indications for Blowhole Incisions
Blowhole incisions should ONLY be considered when subcutaneous emphysema becomes life-threatening and conservative measures have failed. 3, 2
Specific Life-Threatening Criteria:
- Acute airway obstruction or thoracic compression causing respiratory compromise 3
- Palpebral closure preventing vision 6
- Severe dysphagia or dysphonia 6
- Associated "tension phenomenon" with respiratory failure 6
- Persistent severe symptoms despite adequate chest tube drainage 2, 7
Technique When Blowhole Incisions Are Necessary
If life-threatening subcutaneous emphysema persists despite optimizing chest tube management:
Preferred Modern Approach:
Make a 2-5 cm infraclavicular incision 2 cm below the clavicle through the pectoralis major fascia, then apply negative pressure wound therapy (VAC dressing at -125 mmHg). 8, 9
- This modified technique provides sustained drainage and prevents reaccumulation 8, 9
- Mean duration of VAC therapy is 7.5 days with 1-2 dressing changes 8
- All patients in reported series showed immediate improvement 8, 9
- No wound infections or complications occurred with this approach 8, 9
Alternative Technique:
- Simple blowhole incision without VAC therapy can be used 3, 2
- However, this is more invasive, carries potential for cosmetic defect, and may be less effective in ventilated patients 2, 8
Alternative to Incisions:
Insertion of large-bore (26F) fenestrated subcutaneous drains under low suction (-5 cm H2O) is equally effective and less invasive than incisions. 6, 2
- Provides rapid sustained relief 6, 2
- Can be enhanced with regular compressive massage 2
- Avoids cosmetic defect of incisions 2
Critical Management Pitfalls
- Never clamp a bubbling chest tube - this is the most dangerous error and primary cause of worsening subcutaneous emphysema 3, 1, 4, 5
- Do not place prophylactic subcutaneous drains at surgical incisions for infection prevention - evidence shows no benefit 3, 1
- Do not rush to blowhole incisions when optimizing existing chest tube management may suffice 2
- Ensure strict aseptic technique if any intervention is performed - empyema risk is 1-6% with chest tube procedures 3, 5
Special Consideration for Mechanically Ventilated Patients
In ventilated patients with severe subcutaneous emphysema, blowhole incisions with negative pressure wound therapy are particularly indicated because mechanical ventilation continuously generates air. 8