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Spontaneous subcutaneous and mediastinal emphysema is a rare but potentially dangerous complication of delivery. The condition was observed in a 24-year-old, small and slightly-built primipara after vaginal delivery of a large infant.
We report a series of intraoperative complications of laparoscopic cholecystectomy. Three cases are presented in which subcutaneous emphysema associated with pneumomediastinum, pneumoscrotum, and pneumothorax with pneumomediastinum and ocular emphysema, respectively, developed intraoperatively. These events resulted in no major morbidity to these patients. Use of N2O and monitoring of airway and intraabdominal pressures are discussed.
Pneumothorax, pneumomediastinum, pneumopericardium, and subcutaneous emphysema have been described as complications of laparoscopy. This study evaluates the incidence and significance of these extra alveolar collections of air. We found that pneumomediastinum with or without pneumothorax was not associated with significant morbidity and is more likely after laparoscopic fundoplication than other laparoscopic surgeries. The presence of pneumomediastinum after fundoplication is a normal finding. However, pneumothorax has clinical significance and should be considered pathological.
Leg pain may be a presenting symptom of intra-abdominal disease. I report a case of subcutaneous emphysema of the thigh that was a complication of diverticular perforation and abscess formation. Healthy leg muscle was found at operation, showing that myonecrosis need not necessarily be present even with finding of extensive gas accumulation.
Rabies is a rare, fatal viral infection, usually transmitted by the bite of an infected animal. Some 30,000 Americans are immunized annually, however, so public health considerations are common. The development of a new vaccine, grown in human diploid cell culture, is discussed. It appears to have high antigenicity with no serious morbidity. A case of a patient with fatal rabies who had fever, delirium, dysphagia, and cervical and pectoral subcutaneous emphysema is presented.
A 46-year-old man developed respiratory distress with air leak syndrome (ALS), including pneumothorax, pneumomediastinum, and subcutaneous emphysema. Open lung biopsy was performed and revealed the histopathologic evidence of bronchiolitis obliterans organizing pneumonia (BOOP), which responded well to steroid treatment. As far as we know, this appears to be the first case of BOOP presenting with ALS as one of its major complications.
Traumatic bronchial rupture is a rarity. Its incidence is about 1.5% to 3% in most series of blunt chest trauma. We report a patient who presented after a road traffic accident with an apparently persistent pneumothorax which failed to respond to emergency treatment. This was later discovered to be due to a traumatic bronchial rupture. It is difficult to diagnose traumatic bronchial rupture, the main reason being that it is often not considered by doctors caring for the patient with blunt chest trauma in the Accident and Emergency Department. Failure to recognise this condition contributes to its high mortality. The authors would like to recommend that emergency bronchoscopy be carried out in patients with blunt chest trauma to exclude this potentially treatable condition. This is especially so if there are suggestive clinical features, such as the presence of extensive and spreading subcutaneous emphysema, pneumomediastinum, pneumothorax, haemoptysis, fractures of the first two ribs and respiratory distress. A history of massive blunt force to the chest wall as a mechanism of injury should also prompt the trauma team to consider the need for emergency bronchoscopy.
We describe the first reported case of tracheal necrosis following a thyroidectomy. This complication resulted in massive subcutaneous emphysema and pneumomediastinum, which required emergency exploration of the neck to decompress the trapped air. We also discuss the suggested etiology and management of this rare condition.
PURPOSE: Subcutaneous emphysema following laparoscopy could result in postoperative respiratory acidosis from prolonged CO2 absorption. We studied the magnitude and duration of alterations in PaCO2 coincident with direct CO2 insufflation into the subcutaneous fat of the anterior abdominal wall of 5 anesthetized juvenile pigs. METHODS: First, each pig was insufflated with 6 L of CO2 to produce moderate emphysema over the trunk. Following return to baseline PaCO2, each pig was re-insufflated with 12 L of CO2 to produce severe emphysema over lower limbs, neck, head, and trunk. Measurements of arterial blood gases were performed every 5 or 10 min. Minute ventilation was held constant to represent the worst case scenario. RESULTS: From baseline PaCO2 of 41.8 +/- 2.3 mm Hg, PaCO2 peaked at 68.3 +/- 8.6 (P < 0.02) and 92.9 +/- 10.7 (P < 0.01) mm Hg for the 6- and 12-L volumes, respectively, 20 to 25 minutes following insufflation. From baseline arterial pH of 7.40 +/- 0.02, respective nadirs of pH were 7.21 +/- 0.06 (P < 0.02) and 7.08 +/- 0.05 (P < 0.01). PaCO2 and arterial pH took approximately 100 minutes to return to baseline after insufflation with both 6 and 12 L volumes. CONCLUSIONS: When minute ventilation is fixed, subcutaneous CO2 insufflation causes increased PaCO2 and decreased pH that may persist for a prolonged period of time. Therefore, patients with subcutaneous emphysema after laparoscopy should be observed in postanesthetic recovery until PaCO2 and pH approach baseline.
Massive subcutaneous emphysema developed in three patients following ventilation with an oxygen-powered, positive pressure resuscitator used by an urban emergency medical service. A faulty valve regulator was identified as the source of the problem. Following this discovery, an extensive field test of all oxygen-powered resuscitators used by the emergency service was carried out. Sixty resuscitators were tested, 15 of which (25%) were found to be deficient on at least one of the test criteria. It is strongly recommended that all personnel using these devices be trained to recognize equipment malfunction and that periodic performance evaluations be carried out on all such equipment. The results of this field test, and other performance tests done previously, raise questions about the use of positive pressure resuscitators in the emergency setting.
We have presented two unusual cases of nasogastric tube perforation of the posterior nasopharynx. Complications included subcutaneous emphysema, pneumomediastinum, and pleural effusion. Both patients recovered. Recommendations to improve nasogastric tube safety include gentle placement using lubricant and an appropriately sized tube, confirmation of tube placement before any infusion, and awareness of patients at increased risk of mucosal injury.
A 27-year-old healthy woman suffered from dyspnoea and retrosternal pain after a spontaneous vaginal delivery due to a pneumomediastinum and subcutaneous emphysema caused by labour.
A 46-year-old woman was admitted to our hospital for a severe asthma attack. On admission, systemic cyanosis was observed, and her consciousness state was drowsy. Arterial blood gas showed severe respiratory acidosis, hypoxia, and hypercapnea, with pH, PaO2, and PaCO2 of 7.163, 29.9 torr and 81.3 torr, respectively. Immediately, mechanical ventilation was commerced but on the third hospital day pneumomediastinum and subcutaneous emphysema appeared, and on the sixth day pneumoperitoneum also appeared. The chest CT scan on the sixth day showed free air around bilateral internal mammary vessels. This indicated that air moved from the mediastinum into the peritoneal cavity through an anterior route, via the sternocostal triangle formed by the xiphoid origins of the diaphragm medially and the costal origins laterally.
We report a rare case of a patient in whom severe subcutaneous and mediastinal emphysema occurred in association with summer-type hypersensitivity pneumonitis and in whom overdistention or disruption of alveoli with obliteration of the respiratory bronchioles was revealed on open lung biopsy. This case suggests that obstructive bronchiolitis with hypersensitivity pneumonitis is an etiologic factor of mediastinal emphysema.
Spontaneous rupture of the pulmonary alveoli after a sudden increase in intra-alveolar pressure is a common cause of pneumomediastinum, which is usually seen in healthy young men. Other common causes are traumatic and iatrogenic rupture of the airway and esophagus; however, pneumomediastinum following cervicofacial emphysema is much rarer and is occasionally found after dental surgical procedures, head and neck surgery, or accidental trauma. We present four cases of subcutaneous emphysema and pneumomediastinum with two secondary pneumothoraces after self-induced punctures in the oral cavity. They constitute an uncommon clinical entity that, to our knowledge, has not been reported in the literature. Its radiologic appearance, clinical presentation, and diagnosis are described.
An 11-year-old girl with an almond lodging in the tracheobronchial tree is described. She presented with an uncommon symptom of subcutaneous emphysema The x-ray revealed left-sided pneumothorax and pneumomediastinum. Intercostal drain was inserted, but she developed respiratory failure and was ventilated. After initial stabilization for 60 hours, she deteriorated again and her x-ray revealed right-sided collapse. After removal of the foreign body, she was discharged but presented again with stridor necessitating tracheostomy. Tracheal stenosis was found and required end-to-end anastomosis. The authors feel that, while foreign bodies are uncommon in this age group with emphysema as a rarer manifestation, this cause should be kept in mind, even in the absence of forthcoming history. A high index of suspicion for tracheobronchial foreign body is required in atypical presentations of acute pediatric respiratory distress.
OBJECTIVE: Ruptures of the tracheobronchial tree present a life-threatening situation. Nevertheless, therapy is still controversial. Though conservative treatment by antibiotics and intubation with the cuff inflated distal to the tear is favored by some authors, surgical repair is unavoidable in many cases. METHODS: We present a series of 31 patients (mean age 43.6 years, range 8--72 years) with iatrogenous or post-traumatic tracheobronchial ruptures treated since 1975. Fifteen ruptures were longitudinal tears of the trachea, not extending lower than a distance of 3 cm from the bifurcation, 11 involved the bifurcation and/or the main bronchi. The total length of the longitudinal tears ranged from 2 to 12 cm, five were transverse near complete abruptions of the trachea or main bronchi. Involvement of the full thickness of the wall with free view into the pleural space or to the esophageal wall was present in 29 cases. Twenty-nine out of the 31 patients underwent surgical repair and two were treated conservatively. The length and depth of the lesion, the degree of subcutaneous emphysema, pneumothorax and/or pneumomediastinum as well as clinical signs suggesting incipient mediastinitis were considered when making the decision for surgery. RESULTS: Twenty-five out of the 29 patients experienced an uneventful recovery. Four patients died of sepsis unrelated to the tracheobronchial trauma. One of the two patients who underwent conservative therapy also recovered uneventfully. The other one died because of multi-organ failure due to underlying myocardial infarction. CONCLUSIONS: Conveniently localized short lacerations, especially if they do not involve the whole thickness of the tracheal wall, can be treated with antibiotics and intubation with the cuff inflated distal to the tear, avoiding high intra-bronchial pressures also after eventual extubation. In all other cases surgical repair is to be preferred.
Retropharyngeal and mediastinal emphysema is associated with traumatic aerodigestive tract injury, and may be associated with potentially severe and even life-threatening complications. Retropharyngeal emphysema or pneumomediastinum, in the absence of severe trauma to the visceral organs, is rare following facial fractures. We report a case of extensive subcutaneous emphysema extending to the retropharyngeal space and mediastinum following an orbitozygomatic fracture.