What does crepitus over the chest wall after chest tube insertion indicate and how should it be evaluated and managed?

Crepitus After Chest Tube Insertion: Evaluation and Management

What Crepitus Indicates

Crepitus over the chest wall after chest tube insertion indicates subcutaneous emphysema—air tracking through subcutaneous tissues—which most commonly results from air leaking around the chest tube insertion site or from ongoing pleural air leaks that exceed drainage capacity. 1

The presence of subcutaneous emphysema signals one of several underlying problems:

• Air leak around the tube insertion site due to inadequate closure of the incision or improper tube securing 2
• Persistent bronchopleural fistula with air leak exceeding the drainage capacity of the chest tube 1
• Malpositioned or kinked chest tube preventing adequate drainage of pleural air 3
• Underlying severe chest injury when subcutaneous emphysema develops rapidly or extensively 4, 5

Immediate Clinical Assessment

Evaluate the severity and extent of subcutaneous emphysema systematically:

• Check for airway compromise immediately—palpate the neck for crepitus tracking upward, assess for vocal changes, stridor, or respiratory distress, as extensive subcutaneous emphysema can cause life-threatening airway obstruction 5, 6
• Assess hemodynamic stability and look for signs of tension pneumothorax (hypotension, tachycardia, tracheal deviation, distended neck veins) 4
• Document the extent of crepitus—map whether it involves only the chest wall, extends to the neck/face, or involves the limbs, as extensive distribution indicates severe underlying air leak 1, 4
• Examine the chest tube insertion site for proper securing, signs of tube displacement, or visible air leaking around the tube 2

Diagnostic Evaluation

Obtain a chest radiograph immediately to assess tube position, residual pneumothorax, and the extent of subcutaneous air. 2, 3

Additional imaging considerations:

• Order CT chest if bullous lung disease is suspected, as emphysematous bullae can mimic pneumothorax and inserting or manipulating tubes in this setting is dangerous 7
• CT is also indicated if tube position is unclear or if loculated pneumothorax is suspected, as this requires image-guided drainage rather than tube repositioning 3

Management Algorithm

Step 1: Ensure Tube Function

• Verify the chest tube is patent and bubbling appropriately in the water seal chamber—continuous bubbling indicates ongoing air leak 2
• Never clamp a bubbling chest tube, as this converts a simple pneumothorax into life-threatening tension pneumothorax 3, 8
• Check that the drainage system is below chest level and connections are airtight 2

Step 2: Optimize Drainage

• Apply suction at -10 to -20 cm H₂O using high-volume, low-pressure systems if not already in use, as this may improve air evacuation and reduce subcutaneous tracking 8
• Consider upsizing to a larger chest tube (24-28F) if the current tube is small-bore and there is a large persistent air leak, particularly in mechanically ventilated patients 3, 8

Step 3: Secure the Insertion Site

• Reinforce closure of the chest tube insertion site with additional sutures to prevent air tracking around the tube into subcutaneous tissues 2
• Ensure the tube is well-secured with stay sutures or fixation devices to prevent tube migration 2

Step 4: Address Persistent or Severe Subcutaneous Emphysema

For mild, stable subcutaneous emphysema without airway compromise:

• Observe with maximized chest tube suction as most cases resolve spontaneously once the air leak is controlled 1, 9
• Monitor closely for progression, particularly in patients with hydropneumothorax, secondary pneumothorax, or large air leaks, as these are at higher risk for severe subcutaneous emphysema 1

For recalcitrant subcutaneous emphysema (persisting despite optimized chest tube management):

• Consider placement of subcutaneous cannulas (14G) in the anterior chest wall for rapid decompression—this is a simple, minimally invasive technique that provides immediate symptom relief 6
• Refer for video-assisted thoracoscopic surgery (VATS) with pneumolysis if subcutaneous emphysema persists beyond 24-48 hours despite interventions, as this directs the air leak back into the pleural space and significantly shortens hospital stay 9

For extensive subcutaneous emphysema with airway compromise:

• Secure the airway immediately with rapid-sequence intubation before complete airway obstruction occurs 5
• Insert additional chest tubes or upsize existing tubes to maximize pleural drainage 5, 6
• Place subcutaneous cannulas emergently for decompression of subcutaneous air 6

Critical Pitfalls to Avoid

• Never reposition a functioning chest tube based solely on radiographic appearance, as this risks creating additional pleural injury and worsening air leak 2
• Never use sharp metal trocars for chest tube insertion or reinsertion, as these cause catastrophic organ injuries 3
• Do not delay airway intervention in patients with rapidly progressive subcutaneous emphysema involving the neck—these patients can deteriorate within minutes 5
• Recognize that delayed presentations are possible—patients may develop severe subcutaneous emphysema 24+ hours after initial chest injury 5

When to Escalate Care

• Refer to respiratory specialist at 48 hours if pneumothorax fails to respond or persistent air leak continues 8
• Consider earlier surgical referral (2-4 days) in patients with underlying lung disease (COPD, bullous disease), large persistent air leak, or failure of lung to re-expand 8
• Immediate surgical consultation is warranted for airway compromise, hemodynamic instability, or recalcitrant subcutaneous emphysema unresponsive to conservative measures 5, 9