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Communications to the Editor |

Efficacy of Microdrainage in Severe Subcutaneous Emphysema FREE TO VIEW

Francesco Leo, MD, FCCP; Piergiorgio Solli, MD; Giulia Veronesi, MD; Lorenzo Spaggiari, MD, PhD, FCCP; Ugo Pastorino, MD
Author and Funding Information

European Institute of Oncology Milan, Italy

Correspondence to: Francesco Leo, MD, FCCP, Thoracic Surgery Department, University Hospital of Nice, 30 Av de la Voie Romaine, Nice 06002, France; e-mail: francescoleo@interfree.it



Chest. 2002;122(4):1498-1499. doi:10.1378/chest.122.4.1498-a
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To the Editor:

Severe subcutaneous emphysema may complicate the postoperative period of patients who undergo thoracic surgery. Although the condition rarely is life-threatening, discomfort from cutaneous tension and palpebral occlusion, as well as an increase of air with coughing may impair the efficacy of chest physiotherapy and, in the end, negatively affect postoperative recovery. Several techniques have been described for the management of this complication.13

At the European Institute of Oncology (IEO), since 1998 we have routinely used the subcutaneous drainage of emphysema by manually fenestrated angiocatethers, a technique that was described in the case report by Beck et al in CHEST (February 2002).4 In reviewing the IEO database for the period under consideration (January 1998 to September 2001), we concluded that 1,008 major thoracic operations were performed and that severe subcutaneous emphysema needing microdrainage had been recorded for 11 patients (1.1%). One additional patient developed diffuse cervical emphysema after undergoing mediastinoscopy (1 of 288 patients [0.4%]) without showing any tracheobronchial or esophageal lesion and without concomitant pneumothorax. In three patients, a chest drain was inserted before subcutaneous microdrainage was begun.

Subcutaneous emphysema was resolved 1 to 3 days by microdrainage in all patients but one, who developed further subcutaneous emphysema without pneumothorax at the time of chest drain removal. Two additional days of microdrainage were sufficient to resolve the problem. No complications from the procedure were recorded.

From this series of 12 patients, some questions left open by the case report of Beck et al can be answered. The previously mentioned risk of infection from the catheter is present but, as long as a rigorous asepsis is maintained during placement of the catheter, it is not higher than the risk of infection for central venous catheters. No infection was recorded in our series, probably because the catheters remained in place for ≤ 3 days.

The second question is, how long does the catheter work? Our answer is, not more than 3 days. Usually, at the time of removal, the catheter is obstructed by clots and dislodged by the movements of the subcutaneous and muscular planes. Fortunately, at that time almost all cases are resolved.

Two additional technical notes can be added. A 3-mm incision in the skin with a No. 11 blade under local anesthesia was used in all cases to position the catheter. At the time of removal, the small opening allowed for the exit of residual air for an additional 12 to 24 h. No long-term cosmetic problems were recorded.

Finally, the positioning of the catheters alone is generally not adequate to obtain immediate symptom relief, which is the target of the procedure. A compressive massage of the upper limbs from the hands toward the shoulder and from the facial region to the supraclavicular fossae helps to convey the air down, allowing it to exit through the catheters. The nursing staff should learn the maneuver and should repeat it 3 to 4 times per day.

On the basis of our results, we agree with the conclusions of Beck et al. The technique of microdrainage of severe subcutaneous emphysema is safe, easy, and effective, affording immediate symptom relief.

Herlan, DB, Landrenau, RJ, Ferson, PS (1992) Massive spontaneous subcutaneous emphysema: acute management with infraclavicular “blow holes.”Chest102,503-505
 
Terada, Y, Mastunobe, S, Nemoto, T, et al Palliation of severe subcutaneous emphysema with use of a trocar-type chest tube as a subcutaneous drain [letter]. Chest. 1993;;103 ,.:323
 
Kelly, MC, McGuigan, JA, Allen, RW Relief of tension subcutaneous emphysema using a large bore subcutaneous drain.Anaesthesia1995;50,1077-1079
 
Beck, PL, Heitman, SJ, Mody, CH Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema.Chest2002;121,647-649
 

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References

Herlan, DB, Landrenau, RJ, Ferson, PS (1992) Massive spontaneous subcutaneous emphysema: acute management with infraclavicular “blow holes.”Chest102,503-505
 
Terada, Y, Mastunobe, S, Nemoto, T, et al Palliation of severe subcutaneous emphysema with use of a trocar-type chest tube as a subcutaneous drain [letter]. Chest. 1993;;103 ,.:323
 
Kelly, MC, McGuigan, JA, Allen, RW Relief of tension subcutaneous emphysema using a large bore subcutaneous drain.Anaesthesia1995;50,1077-1079
 
Beck, PL, Heitman, SJ, Mody, CH Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema.Chest2002;121,647-649
 
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