(Chest. 2002;121:647-649.)
© 2002
American College of Chest Physicians
Simple Construction of a Subcutaneous Catheter for Treatment of Severe Subcutaneous Emphysema*
Paul L. Beck, MD;
Steven J. Heitman, MD and
Christopher H. Mody, MD, FCCP
*
From the Department of Internal Medicine, University of Calgary, Calgary, AB, Canada.
Correspondence to: Christopher H. Mody, MD, FCCP, Rm 273 Heritage Medical Research Building, University of Calgary, Calgary, AB, Canada, T2N 4N1; e-mail: cmody{at}ucalgary.ca
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Abstract
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Subcutaneous emphysema often presents a management dilemma.
Rarely, subcutaneous emphysema has pathophysiologic consequences. More
often, it is extremely uncomfortable for the patient, and is often
disfiguring and alarming for patients and family. When subcutaneous
emphysema is severe, physicians may feel compelled to treat it, but the
currently described techniques are often invasive or ineffective. We
describe the use of an easily constructed, minimally invasive,
fenestrated catheter that relieves the symptoms of subcutaneous
emphysema.
Key Words: AIDS • complications • Pneumocystis carinii pneumonia • pneumothorax • subcutaneous emphysema • therapy
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Introduction
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Subcutaneous
emphysema often presents a therapeutic dilemma when it progresses
beyond the stage of tactile fascination. Even when it is severe,
subcutaneous emphysema rarely has pathophysiologic consequences, but it
is extremely uncomfortable for the patient, and physicians may feel
compelled to treat it. The widely employed methods of therapy, which
include placing chest tubes,1
or lacerating the skin on
the anterior chest,2
are time-consuming and uncomfortable.
The lacerations often clot and, thus, are ineffective, frequently
leaving scars. Here, we describe the use of an easily constructed
fenestrated catheter that relieves subcutaneous emphysema.
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Case Report
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A 50-year-old man presented to his family doctor with an
exacerbation of COPD. He was initially treated with albuterol and oral
steroid therapy (40 mg po once daily, then tapering). The
patient’s medical history was noncontributory, except for a 50
pack-year smoking history, and he had lost approximately 20 lb over the
previous 2 to 3 months. Within a few days, fevers, chills, rigors, and
a dry cough developed. He was admitted to the hospital in respiratory
distress. His chest radiograph at hospital admission showed signs of
bullous lung disease and bilateral fine reticular infiltrates. The
working diagnosis was COPD and community-acquired pneumonia, and he was
started on cefuroxime and erythromycin therapy. His condition
deteriorated, and bronchoscopy and a transbronchial biopsy were
performed. Pneumocystis carinii was confirmed by testing of
the biopsy specimen, and he was started on therapy with
trimethoprim/sulfamethoxazole and corticosteroids. The results of his
HIV serology tests were positive. Following the biopsy, his condition
continued to deteriorate, and he was transferred to the ICU because of
respiratory failure. He required intubation, and two chest tubes were
inserted for a large right pneumothorax.
Over the next 5 weeks, the patient had numerous chest tubes inserted
for recurrent pneumothoraces and a persistent air leak with
subcutaneous emphysema. After 5 weeks and 12 chest tubes, the patient
refused to have any additional chest tubes placed, and he had declined
a surgical consultation. However, the subcutaneous emphysema was severe
enough to completely close his eyes and made it difficult for him to
breathe and swallow (Fig 1
). The patient did not want to live if he could not see his family.
Thus, no further intervention was attempted, and the subcutaneous
emphysema worsened over the subsequent 7 days. The patient continued to
refuse surgery and the placement of further chest tubes, and he stated
that he would discharge himself and commit suicide if nothing
could be done. Subcutaneous punctures relieved the emphysema for a few
hours until the blood clotted or the wound healed over. A literature
search failed to reveal any additional techniques that were acceptable
to the patient.
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Figure 1.. The appearance of the patient before
(left) and 4 days after (right) the
placement of bilateral fenestrated subcutaneous catheters. Note that
lacerations on the anterior chest can be seen in the picture taken
before catheter placement, which did not control the subcutaneous
emphysema. The patient described in this report provided informed
consent for the procedures and for the photographs.
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With the patient’s consent, we created fenestrations in two 14-gauge
angiocatheters (Fig 2
) and inserted them into the subcutaneous space bilaterally at the
midclavicular line overlying the second intercostal space. The
angiocatheters were placed using a sterile technique and were fastened
into place with 3–0 silk suture. The angiocatheters relieved the
subcutaneous emphysema, and this greatly improved the patient’s
spirits (Fig 1)
. There were no signs of infection at the angiocatheter
sites and no pain from the angiocatheters. The subcutaneous emphysema
and pneumothorax resolved in 3 days, and the angiocatheters were
removed after 5 days. There was no further recurrence of either the
pneumothorax or the subcutaneous emphysema. The patient was discharged
4 days later and lived at home for an additional 1.5 years until his
death from sepsis.
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Figure 2.. Fenestrations were cut in a spiral pattern along
the length of a 14-gauge angiocatheter. No more than eight holes were
cut into the catheter so that it retained strength. Care was taken to
remove any burrs so that the catheter could be easily inserted and
removed.
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Discussion
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The catheters are easily constructed. The fenestrations are
readily created by leaving the angiocatheter over the steel stylette
and using a scalpel blade to create the holes. To enhance the rigidity
of the catheter, the fenestrations are created in a spiral pattern. A
povidone-iodine swab is used to prepare the skin and, if desired, a
small amount of local anesthetic can be used. The site of insertion is
2 to 3 cm lateral to the midclavicular line over the third rib. The
catheter is inserted medially at a 45° angle until the tip is
approximately 0.5 to 1 cm deep into the skin that has been expanded by
the subcutaneous emphysema. The angle of insertion then is decreased,
and the catheter is directed medially so that it is completely inserted
and the tip is approximately 1 to 1.5 cm deep into the skin.
For subsequent patients, the catheter was not sutured into place but
was held in place with a 2 x 2-inch gauze pad taped over the
end of the catheter, which allows for the free escape of subcutaneous
air. Precautions should be used to keep the catheter clean, and at the
first sign of any infection the catheter should be removed (a new
catheter can be placed in a new site if needed).
The patient described here had had numerous chest tubes placed and
refused further insertions. It is likely that the air leak resolved at
about the time that the subcutaneous catheters were placed. It is
interesting to note that the pneumothorax also resolved following the
placement of the subcutaneous catheters. The catheters likely work by
providing a portal for air to exit along well-defined tissue planes.
Although the subcutaneous catheters were draining the pleural air as
well as the subcutaneous air, the process resolved much more quickly
than we would have expected for either condition. In subsequent
patients with continuing air leaks, we have found that the catheters
improve the subcutaneous emphysema but may not improve the
pneumothorax.
The mechanism of pulmonic interstitial emphysema, pneumomediastinum,
and subcutaneous emphysema has been studied
experimentally.3
4
In studies of a variety of diseases and
in animal models, it has been demonstrated that air leaks from
ruptured alveoli into the loose connective tissue surrounding the
pulmonary vasculature and tracks along the perivascular space to the
mediastinum. In this classic work,3
4
the authors
were unable to demonstrate the presence of air along the peribronchial
sheath, along the lymphatics, or along the septa of the secondary
lobules. Further, they thought that, even in the setting of an
iatrogenic pneumothorax, pneumomediastinum and subcutaneous emphysema
were more likely to be the result of pulmonic interstitial emphysema
than the direct movement of air from the pleural space to the
subparietal space through a tear in the parietal pleura. By inference,
air then tracks from the mediastinum to the loose subcutaneous tissue,
causing subcutaneous emphysema.
A number of techniques have been employed to treat subcutaneous
emphysema, many of which are invasive or uncomfortable, and may
themselves cause subcutaneous emphysema.5
These include
infraclavicular incisions,2
the placement of additional
chest tubes either in the intrapleural space or
subcutaneously,6
tracheostomy,7
and
large-bore subcutaneous drains with or without suction.8
9
The catheter described here does not require an incision, does not
require suction, and is less likely to produce a scar than the
previously described techniques. While we have not experienced problems
with the catheter described here, there are two potential problems. The
first is infection, and the second is that the catheter may become
blocked with blood. Because the catheter is easily replaced in a
slightly different location, our policy has been to replace the
catheter at the first sign of any problem.
Subcutaneous emphysema, even when severe, is often nothing more
serious than a cosmetic problem. Certainly, it can make nursing care
difficult because the patient may develop dysphagia10
or
vision problems because of periorbital swelling, as did our patient.
More severe complications have been rarely reported. These
complications include respiratory failure,11
12
pacemaker
malfunction,13
14
airway compromise,15
16
and
tension phenomena.8
17
18
Under these conditions, the
catheter described here, or other previously described techniques,
should be employed rapidly. The ease of construction of the catheter
described here will allow physicians to treat subcutaneous emphysema
earlier in its course and prevent severe complications.
In summary, we describe a simply constructed catheter that can be used
for subcutaneous emphysema. It is made with equipment that is available
on most medical wards and can be easily placed by the physician at the
bedside. The goal is to relieve the discomfort and to prevent
complications associated with subcutaneous emphysema.
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Acknowledgements
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The authors thank Dr. Stephen K. Field, MD, FCCP,
for his careful review of the manuscript.
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Footnotes
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Dr. Beck is a Clinical Investigator of the Alberta Heritage Foundation
for Medical Research, and Dr. Mody is a Scholar of the Alberta Heritage
Foundation for Medical Research.
Received for publication November 10, 2000.
Accepted for publication June 27, 2001.
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References
|
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-
Mattox, KL, Allen, MK (1986) Systematic approach to pneumothorax, hemothorax, pneumomediastinum and subcutaneous emphysema. Injury 17,309-312[Medline]
-
Herlan, DB, Landreneau, RJ, Ferson, PF (1992) Massive spontaneous subcutaneous emphysema: acute management with infraclavicular "blow holes." Chest 102,503-505[Abstract/Free Full Text]
-
Macklin, CC (1939) Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: clinical implications. Arch Intern Med 64,913-926[Abstract/Free Full Text]
-
Macklin, MT, Macklin, CC (1944) Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: an interpretation of the clinical literature in the light of laboratory experiment. Medicine 23,281-358
-
Crouch, JD, Keagy, BA, Delany, DJ (1987) "Pigtail" catheter drainage in thoracic surgery. Am Rev Respir Dis 136,174-175[ISI][Medline]
-
Terada, Y, Matsunobe, S, Nemoto, T, et al (1993) Palliation of severe subcutaneous emphysema with use of a trocar-type chest tube as a subcutaneous drain [letter]. Chest 103,323
-
Lopez Gonzalez, MA, Cordero Fraile, T, Delgado Moreno, F (1997) Tracheostomy as a solution for subcutaneous emphysema and pneumomediastinum with severe respiratory failure. Acta Otorrinolaringol Esp 48,677-681[Medline]
-
Kelly, MC, McGuigan, JA, Allen, RW (1995) Relief of tension subcutaneous emphysema using a large bore subcutaneous drain. Anaesthesia 50,1077-1079[ISI][Medline]
-
Sherif, HM, Ott, DA (1999) The use of subcutaneous drains to manage subcutaneous emphysema. Tex Heart Inst J 26,129-131[Medline]
-
Shuster, MJ (1981) Pneumomediastinum as a cause of dysphagia and pseudodysphagia. Ann Emerg Med 10,648-651[Medline]
-
Eveloff, SE, Donat, WE, Aisenberg, R, et al (1991) Pneumatic chest wall compression: a cause of respiratory failure from massive subcutaneous emphysema. Chest 99,1021-1023[Abstract/Free Full Text]
-
Conetta, R, Barman, AA, Iakovou, C, et al (1993) Acute ventilatory failure from massive subcutaneous emphysema. Chest 104,978-980[Abstract/Free Full Text]
-
Giroud, D, Goy, JJ (1990) Pacemaker malfunction due to subcutaneous emphysema. Int J Cardiol 26,234-236[Medline]
-
Santomauro, M, Ferraro, S, Maddalena, G, et al (1992) Pacemaker malfunction due to subcutaneous emphysema: a case report. Angiology 43,873-876
-
Gibney, RT, Finnegan, B, FitzGerald, MX, et al (1984) Upper airway obstruction caused by massive subcutaneous emphysema. Intensive Care Med 10,43-44[ISI][Medline]
-
Anderson, JA, Tucker, MR, Foley, WL, et al (1991) Subcutaneous emphysema producing airway compromise after anesthesia for reduction of a mandibular fracture: a case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 71,275-279
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Coelho, JC, Tonnesen, AS, Allen, SJ, et al (1985) Intracranial hypertension secondary to tension subcutaneous emphysema. Crit Care Med 13,512-513[ISI][Medline]
-
van Berkel, M, Dijkman, JH (1990) Tension subcutaneous emphysema: a case report. Neth J Med 36,25-28[Medline]
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Abstract
Introduction
