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|Year : 2014 | Volume
| Issue : 2 | Page : 217-218
A novel treatment modality for extensive subcutaneous emphysema
JC Suri, A Ray, A Khanna, NS Chitte
Department of Pulmonary Critical Care and Sleep Medicine, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India
|Date of Web Publication||13-May-2014|
Dr. A Ray
Department of Pulmonary Critical Care and Sleep Medicine, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Suri J C, Ray A, Khanna A, Chitte N S. A novel treatment modality for extensive subcutaneous emphysema. J Postgrad Med 2014;60:217-8
We report a case of extensive subcutaneous emphysema (ESE) following spontaneous pneumomediastinum in a case of chronic obstructive pulmonary disease (COPD) who was treated with a novel method of subcutaneous emphysema drainage with a fenestrated central venous catheter (CVC).
A 46-year-old male, patient, a known case of COPD, presented with sudden onset of swelling over, face, neck, chest and upper limbs of 1-day duration. There was no history of trauma. Examination revealed subcutaneous emphysema involving face [causing closure of bilateral palpebral fissure], neck, chest and upper limbs [Figure 1]. Respiratory rate, blood pressure and heart rate were within normal limits. Arterial blood gas analysis revealed mild hypoxemia [PaO 2 - 66 mmHg]. Complete blood count, liver and renal function tests were normal. HRCT thorax showed bilateral bulla with pneumomediastinum and extensive subcutaneous emphysema [Figure 2].
|Figure 2: CECT Chest of the patient showing pneumomediastinum and extensive subcutaneous emphysema|
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Initially, we inserted fenestrated venflons  bilaterally into the subcutaneous space at the mid-clavicular line over the second intercostal space. The venflon was placed and fastened with adhesives, and attached to an underwater seal for drainage. Repeated compressive massage , was performed toward the catheter with an aim to facilitate drainage. However, after initial bubbling in the underwater drain no further bubbling was observed. The catheter when withdrawn was seen to be kinked at multiple sites. It was inferred that the catheter got kinked due lack of rigidity. Next, we used a central venous catheter [VenX CVC set, single lumen 7 Fr, B L Life Sciences, India] and created oval fenestrations [approx. 5 mm × 2 mm] with the help of a scalpel. Under local anesthesia and full antiseptic, the fenestrated CVC was inserted using the Seldinger technique, and secured to the skin with the help of 3-0 silk sutures and connected to the underwater seal. Next compressive massage  was applied to the affected area, the direction of massage being toward the catheter. Profuse bubbling and significant improvement in SE was noted over the next few hours. There was resolution of the SE and the catheter was removed after 24 hours [Figure 3]. Conservative treatment with high-flow oxygen and inhalers were continued. The patient's swelling decreased substantiallyand he was discharged after 48 hours.
The procedure was easy, inexpensive and no surgical expertise was needed. It was almost painless and could be completed in a short time. As compared to fenestrated venflons fenestrated CVC were more rigid and hence kinking was not encountered. Also the longer length required only a single CVC. Visualization of bubbling in the underwater seal was used to guide the effectiveness of compressive massage. Resolution of swelling was noticed after 8 hours and the catheter was removed after 24 hours. As compared to previous reports where the median time of improvement was 3.7 days,  this technique ensured an earlier resolution.
| :: References|| |
|1.||Beck PL, Heitman SJ, Mody CH. Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema. Chest 2002;121:647-9. |
|2.||Cesario A, Margaritora S, Porziella V, Granone P. Microdrainage via open technique in severe subcutaneous emphysema. Chest 2003;123:2161-2. |
|3.||Srinivas R, Singh N, Agarwal R, Agarwal AN. Management of extensive subcutaneous emphysema and pneumomediastinum by micro-drainage: Time for a re-think? Singapore Med J 2007;48:e323-6. |
[Figure 1], [Figure 2], [Figure 3]
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|[Pubmed] | [DOI]|