Severe Subcutaneous Emphysema
75-year-old man with chronic obstructive pulmonary disease underwent lung-volume–reduction surgery of the right upper lobe by means of video-assisted thoracoscopy. Postoperatively, a right apical pneumothorax and subcutaneous emphysema developed. The subcutaneous edema gradually worsened to extend from the pelvis to the face. Inspiratory stridor developed, and the patient was transferred to the intensive care unit. On physical examination, there was swelling of the face that prevented the eyes from opening, as well as swelling of the neck and chest (Panel A). A 24-gauge chest tube was inserted subcutaneously at the midclavicular line of the third intercostal space. The subcutaneous emphysema decreased considerably over a period of 2 hours (Panel B) and resolved after 5 days (Panel C). The right apical pneumothorax was treated by means of chest-tube thoracostomy. Subcutaneous emphysema typically resolves on its own, but severe cases may lead to airway compromise, as in this patient. The ideal approach to management is not known. One week after removal of the subcutaneous chest tube, the patient was discharged home in good condition. Sulakshan Rasiah, B.M., B.S. Max Whitchurch, M.B., B.S. Epworth HealthCare, Melbourne, VIC, Australia