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BACKGROUND: Emphysema of the abdominal wall occurs after infection with gas-forming organisms or when intraabdominal gas has a mechanical pathway to the retroperitoneum. CASE: Emphysema of the abdominal wall associated with volvulus developed after cesarean delivery. CONCLUSION: Postcesarean abdominal pathology may be associated with emphysema of the abdominal wall.
Cutaneous injuries with crepitus suggest infections caused by gas forming organisms. The non infectious causes of subcutaneous emphysema are under recognized, and are usually of good prognosis. A 27 year old man presented a swollen hand and forearm. He had suffered a small puncture wound in a finger. He had cleaned and dried the area briefly with compressed air, developing a fast swelling of this hand and forearm. At examination, we found extended subcutaneous emphysema in a radiography and observed subcutaneous air in the hand and forearm; 48 hs later there was no evidence of subcutaneous air. The presence of subcutaneous emphysema is always worrisome and such cases must be considered in the differential diagnosis. The exposition of preexistent wounds to compressed air sources (high pressure pneumatic tools, scuba compressed air tubes, compressed air guns) identifies the cause and prevents unnecessary surgical interventions.
The study was carried out on an experimental papain induced model of pulmonary emphysema. The authors assessed the cell populations sampled with lavage. Special emphasis was directed on alveolar macrophages and neutrophils. Extent of emphysema was analysed morphometrically. The authors demonstrated an influx of neutrophils 24 hours after papain was introduced intratracheally. This was followed by a swift decrease of the number of sampled neutrophils. Seven days latter the neutrophil count returned to normal. A significant increase of alveolar macrophages was seen on the seventh day. The increased macrophage count correlated with the extent of the pulmonary emphysema destruction.
OBJECTIVE: To report the operation technique, patient selection and curative effect of single-lung transplantation with contralateral lung volume reduction for a patient with end-stage emphysema. METHODS: A 47-year-old male patient who was dependent on mechanical ventilation because of end-stage emphysema received left-lung transplantation on 20 June, 2003. The surgical technique used was similar to that mentioned in the literature. The donor lung was perfused by low-potassium dextran solutions (LPD) with a cold ischemic time of 390 minutes. The patient received contralateral lung volume reduction because of subacute native lung hyperinflation on the 7th day after operation. He was received tracheostomy on 15th day after operation and was weaned from ventilator on the 26th day post-operation. Immunosuppression included cyclosporine, mycophenolate mofetil and corticosteroid. The acute rejection occurred on the 9th and 15th days after operation and was cured successfully. RESULTS: The lung function was improved significantly and the patient was discharged from hospital 71 days after operation. CONCLUSIONS: Single-lung transplantation combined with contralateral lung volume reduction for end-stage emphysema is an effective measure for subacute native lung hyperinflation. Further follow-up is required to assess the long term results of this procedure.
We describe a case of subcutaneous cervicofacial emphysema in a 21-year-old man who had undergone endotracheal intubation while under general anesthesia 2 months earlier. The emphysema had arisen on the right side of the face and neck and extended to the right shoulder and the cubital fossa. The patient was hospitalized and treated with parenteral antibiotics and hyperbaric oxygen. On hospital day 10, he had improved sufficiently to warrant discharge on the next day. Two months later, the patient presented at a follow-up visit with a recurrence, and he was readmitted. By hospital day 28, his condition had improved and he was scheduled for discharge. However; he experienced another recurrence just before he was to leave the hospital. The circumstances of this second recurrence led us to suspect that the patient was able to produce these signs and symptoms on his own. He was referred for psychiatric evaluation, and findings were negative. He was then sent to the Ear Nose, and Throat Service, where we confirmed that his subcutaneous emphysema could be brought on by Valsalva's maneuver. We performed suspension laryngoscopy and detected two orifices of fistular tracts next to the right vallecula and three at the root of the epiglottis. We repaired the injured mucosa and the orifices of the fistulae with absorbable sutures and cauterized the area. The swelling resolved completely within 4 days, and findings on a radiographic examination of the chest and neck 1 week later were normal. The patient was then lost to follow-up. The presence of air in the retropharyngeal and cervical subcutaneous spaces of the neck and shoulder without pneumomediastinum is an uncommon complication of endotracheal intubation. We discuss the clinical and radiographic findings associated with this complication, and we review diagnostic considerations and management.
BACKGROUND: Congenital lobar emphysema is characterized by overinflation of pulmonary lobe and is caused by localised bronchial obstruction. The disease may result in severe respiratory distress in early infancy. METHODS: Records of children, with congenital lobar emphysema, who were treated at our department between 1997-2003, were reviewed. RESULTS: Three males, aged 16 days till 1 year, were diagnosticed as congenital lobar emphysema. Presenting symptoms were dyspnea in 2 patients, cyanosis in 2 patients, wheesing in 2 patients, recurrent respiratory tract infection in 2 patients. Chest x rays and computerized tomography scans showed hyperinflation of the affected lobe in all patients. The affected sites were left upper lobe in 2 patients and right upper lobe in 1 patient. All patients underwent lobectomy. CONCLUSION: It is necessary to suspect on this uncommon anomaly in early infancy. The diagnosis was established by chest x rays and CT scans. Intensive therapy and urgent lobectomy, in severe respiratory distress, are condition for successfully treatment.
Despite of the clinical studies proving the benefits of lung volume reduction surgery and determining the indications and candidates, the surgical intervention has not penetrated into the standard treatment of emphysema. Perioperative mortality is relatively high at patients with end-stage emphysema, therefore a less invasive procedure might be most useful in medical practice. Bronchoscopic lung volume reduction is a technically simple procedure including insertion of a bronchial blocker (plug) or an endobronchial valve, either totally blocking the air flow, or blocking it only during the inspiration. However, there are only few clinical data available concerning of surgical and bronchial interventions. A multinational clinical study is in progress in three Hungarian pulmonological centers implanting endobronchial plugs into the subsegmental bronchi of patients with severe emphysema.
Hypocomplementaemic urticarial vasculitis syndrome (HUVS) is a rare disorder characterised by complement activation and the presence of C1q precipitins together with a syndrome of urticarial vasculitis, angioedema, arthralgia, ocular inflammation, glomerulonephritis and obstructive lung disease. The pathophysiology of the obstructive airways disease is poorly understood. We report a 46 year-old woman with HUVS who developed progressive obstructive airways disease. Lung biopsy early in the course of her disease revealed pulmonary capillaritis. The disease progressed despite treatment with steroids and cyclosporin and the patient eventually underwent successful double lung transplantation. The explanted lung showed the coexistence of a patchy active vasculitis with severe panacinar emphysema. This is the first description of the histopathological process of HUVS in an explanted lung. Through analysis of serial histopathological specimens and clinical data we show the evolution of pulmonary capillaritis to emphysema, and demonstrate that active vasculitis can coexist with emphysema in patients with HUVS and obstructive airways disease. We suggest that there is a role for ongoing immunosuppressive therapy in these patients.
Anesthesia for abdominal operation in patients with emphysema is accompanied with a high risk of respiratory insufficiency requiring postoperative artificial ventilation. Furthermore, in patients whose pulmonary emphysema progresses and leads to pulmonary hypertension, there is the risk of developing right heart failure with postoperative respiratory insufficiency. Because perioperative circulatory drifting is massive in abdominal operation, they develop right heart failure easily during the postoperative refilling phase. Therefore, it is important to avoid right heart failure during the postoperative period in these patients. We estimate pulmonary artery pressure using echocardiography at bedside and give dopamine for diuresis during the postoperative period. We succeeded in perioperative management of abdominal operation in three patients with pulmonary emphysema associated with pulmonary hypertension.
Subcutaneous emphysema is a relatively rare complication of dental treatment, although increasingly due to the use of high pressure air instruments. Many cases go unrecognized or are misdiagnosed. Majority of patients with this complication resolve spontaneously after 5 to 10 days, however some can advance to potentially life-threatening complications. A case of subcutaneous emphysema during restorative procedure in a 52-year-old woman was treated in the Docent Odontological Clinic of the Frontera University is presented. The differential diagnosis and management of this condition is discussed. Our purpose is not to add one more case of emphysema to literature, but to show dentists that in simple restorative procedures using air pressure instruments, they could be exposed to this complication.
From August 1990 to August 1991, sixteen patients with bullae or blebs (pneumothorax 9, giant bullae 5, bullous emphysema 2) were treated by CO2 laser ablation under limited thoracotomy. We found the irradiation of bullae or blebs by CO2 laser quite effective in eliminating these bullous lesions which were often multiple and inoperable by conventional methods. Histological examination revealed the wall of bullae where CO2 laser was applied became thick with dense fibrous tissues and degenerated collagen fibers which, however, were not disrupted. The procedure was safe and we were able to operate patients with disabling emphysema. Because CO2 laser can penetrate only 0.2-0.3 mm of tissue thickness, it is suitable for the ablation of bullous lesions which have thin walls and rapidly shrink and collapse by irradiation leaving thick walled scar tissues. Removing multiple bullae and blebs in patients with bullous emphysema can improve gas exchange by reducing dead spaces and elevating the diaphragm which is often flat and downward displaced because of hyperinflation in these patients. We are planning to incorporate thoracoscopy for this operation to make the procedure less invasive.
Classic transplantation dogma mandated bilateral lung replacement for lung transplant candidates with end-stage emphysema to avoid air trapping in the native lung and subsequent crowding of the newly transplanted lung. During a recent 12-month period 11 patients with emphysema received a single lung transplant. There was no hospital mortality and only one patient had any notable degree of air trapping in the native lung. Substantial improvement in pulmonary function was seen as early as 2 weeks after transplantation, with significant functional improvement seen by 6 weeks, despite some residual ventilation-perfusion mismatch. We have demonstrated the utility and safety of single lung transplantation for patients with end-stage emphysema, and it is our operation of choice in recipients more than 50 years of age.
The authors publish 8 cases of emphysema of the mediastinum in childhood and adolescence. The aetiologic variety and the radiologic symptoms are presented. Chronic diseases of the lungs and the respiratory tract, injuries of the thorax or iatrogenic genesis are the cause of emphysema. The spontaneous emphysema of the mediastinum is rare in childhood and adolescence.
The benefits of mechanical ventilation with positive end-expiratory pressure (PEEP) are well documented, especially for patients with acute respiratory failure. PEEP increases functional residual capacity (FRC) and reduces closing volume (CV) and ventilation-perfusion mismatching. Little is known about the effects of PEEP in patients with chronic obstructive pulmonary disease, where closing volume and ventilation-perfusion mismatching are increased. We investigated the effects of PEEP in a canine model of panlobular emphysema (PLE). METHODS. After completion of control-period measurements, PLE was induced in eight dogs by intratracheal application of 20 ml aerosolized 16% papain solution. Three weeks later the effects of continuous positive-pressure ventilation (CPPV, PEEP 10 cmH2O) on gas exchange, FRC, and CV were investigated. Conventional intermittent positive-pressure ventilation (IPPV) served as reference. Measurements of CV were done using both the foreign gas bolus method and the single-breath oxygen test. FRC was determined by the nitrogen dilution technique. RESULTS. The papain-induced emphysema produced a deteriation in oxygenation, enlargement of FRC and CV, and an increase in quasi-static lung compliance. CPPV led to a further increase of FRC, but gas exchange was not improved nor was CV reduced. In the PLE period, mean pulmonary arterial pressures (MPAP) were higher during both modes of ventilation. CPPV tended to increase MPAP and pulmonary capillary wedge pressure when compared with IPPV. Systemic hemodynamic conditions were stable throughout the experiment. CONCLUSIONS. The application of PEEP to emphysematous lungs seemed to enlarge FRC, predominantly in the nondependent rather than in the dependent lung regions, which are prone to airway closure. In patients with emphysema, ventilation with PEEP may further deteriorate the impaired distribution of ventilation and thus counteract any improvement of gas exchange.
This is a three case study report of children with measles which later progressed to bronchopneumonia and subcutaneous emphysema. All three children were from farming families, and none had been previously vaccinate against measles. For a period of six months, 183 cases of measles were treated at our hospital of which only three worsened to subcutaneous emphysema, demonstrating an incidence rate of 1.6%; they also showed to have bronchopneumonia, with severe coughing episodes; which made us recall the possible physiopathology principle of the pressure gradient theory behind this complication proposed by Bloch in 1968. The factors related to our patients suggested a more severe and aggresive type of measles with a greater probability of having complications. The prognostic value of the severity of this type of measles in the presence of subcutaneous emphysema is limited and its management should be primarly focused on treating the added bronchial problem.
Spirometric examinations are suitable for the diagnosis of airway obstruction, but not of pulmonary emphysema. Whole body plethysmography, in contrast, is the most reliable diagnostic procedure for both conditions, both qualitatively and quantitatively. The basic treatment of any form of airway obstruction consists in the inhalation of beta-2-sympathomimetic drugs; theophyllines are also good bronchodilators, but are less powerful than beta-2-sympathomimetics. Glucocorticoids must always be given when bronchitis also presents, which is only rarely treatable with antibiotics alone. Although regression of pulmonary emphysema is not possible, progression of the destructive process would appear to be inhibited by intensive treatment of the inflammatory bronchitis. Only in the case of patients with congenital alpha-1-antitrypsin deficiency is it possible to administer such causal treatment in the form of substitution therapy. Surgical treatment can be considered only in the case of bullous pulmonary emphysema.
Although of some value for understanding etiologic mechanisms, the classic diagnostic categories of asthma and emphysema and especially chronic bronchitis have not served clinicians well for defining prognosis and therapeutic options. Until more useful diagnostic categories are available, the choice of diagnostic tests should be guided more by their clinical usefulness than by their sensitivity and specificity for identifying classic diagnostic categories of obstructive lung disease. A history consistent with asthma is as good evidence of asthma as that provided by most tests, especially if combined with spirometric evidence of complete reversibility of episodes of obstruction. Positive bronchial challenge studies and partial responses to bronchodilators are common in asthma but of limited diagnostic specificity. Tests of allergic function are of limited specificity for asthma, although a low IgE level is rare. Findings of reduced expiratory flows, high TLC, and low DLCO, or radiologic signs of hyperinflation, bullae, and pulmonary vascular deficiency pattern are useful for diagnosing cases of severe emphysema, but they are of limited sensitivity for the detection of mild to moderate disease. Advances in high resolution CT offer promise of earlier diagnosis of emphysema. Making a diagnosis of chronic bronchitis based on defined criteria for chronic sputum production is easy but of limited clinical value. Prospective longitudinal studies and advances in technology promise more clinically useful diagnoses in the future.
Surgical treatment for bullous emphysema using Gore-Tex sheet and mechanical stapler is reported. The techniques were followed in a Juetnner's report: Small cut is made at the center of a 10 cm square of a Gore-Tex sheet, through which the area of bullous lung planned for resection is tented out with a lung forceps. A stapling instrument charged with a 4.8 mm clips is placed over the sheet around the suture line, and closed over both sheet and lung parenchyma. The excess sheet is removed after resection of the bullous lung. Five cases of bullous emphysema with a history of pneumothorax were successfully treated by the above method. Air leakage disappeared on the first postoperative day at latest. We assume Gore-Tex sheet, although a non-absorbable material, is in use as well as polydioxanone ribbon for prevention of air leakage in surgical cases of bullous emphysema.