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Communications to the Editor |

Microdrainage Via Open Technique in Severe Subcutaneous Emphysema FREE TO VIEW

Alfredo Cesario; Stefano Margaritora; Venanzio Porziella; Pierluigi Granone
Author and Funding Information

Rome, Italy

Correspondence to: Alfredo Cesario, MD, Division of General Thoracic Surgery, Catholic University, Largo Agostino Gemelli 8, 00168 Rome, Italy; e-mail: alfcesario@yahoo.com



Chest. 2003;123(6):2161-2162. doi:10.1378/chest.123.6.2161
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Published online

To the Editor:

The very interesting and original reports in CHEST by Beck et al (February 2002)1 and Leo et al (October 2002)2 gave us the occasion to review our experience with subcutaneous emphysema and its treatment in patients who have undergone lung parenchyma resections.

In the period between January 1990 and September 2002, we performed 1,561 lung resections. No substantial changes in the surgical technique regarding the parenchyma occurred during this period (essentially, mechanical stapling either at the parenchymal or at the bronchial level), while access changed somewhat and the number of video-assisted thoracoscopic procedures increased in recent years.

The incidence of subcutaneous emphysema associated with symptomatic cutaneous tension, palpebral occlusion, and modifications in tone of voice (defined as “severe” according to the criteria extensively described12 ) was 1.3% (20 patients).

All patients except one had undergone lung resection via open muscle-sparing thoracotomy. In the only patient in whom subcutaneous emphysema developed after a video-assisted thoracoscopic procedure, a limited wedge resection had been performed as treatment for a small hamartochondroma.

In all cases, subcutaneous emphysema was associated with persistent air leakage, as was clinically evident from the output of air into a water valve system connected to the chest drain. A pneumothorax was evident roentgenographically in 19 patients and was the result of a pulmonary collapse of > 50% in eight patients despite the application of continuous aspiration.

All the patients received a cutaneous microincision 5 mm in length in the area of the supraclavicular region, which was performed under local anesthesia usually on the side of the surgical approach. In 13 patients, a bilateral incision was performed due to the presence of massive bilateral subcutaneous emphysema. A separation of the subcutaneous layers up the muscle fascia was always performed via a blunt-tipped instrument and a short, small, and soft Penrose-type rubber drain, which was inserted into the microincision wound to keep it open for the desired period of time. Repeated compressive massage was applied three or more times per day by the nursing staff under the supervision of medical personnel.

The procedure was always performed in completely aseptic conditions. Topical medications were applied repeatedly, usually before and after the compressive massage. Not one patient experienced any infection at the site of the incision.

Symptomatic and psychological relief was immediately obtained in all patients, and repeat local anesthesia was never utilized to perform daily medications and compressive massage. The average duration of treatment was 3.7 days (range, 2 to 6 days), but the data are incomplete in the records of three patients. We have not recorded any complaint regarding the cosmetic outcome.

In conclusion, even if we consider the technique of microdrainage using a manually fenestrated angiocatheter, as described by Beck et al1 and Leo et al,2 as a very good option, the procedure that we adopted, which was far less invasive than the “thoracic lacerations” described by Herlan et al,3 is safe, easy, and effective, and could be considered as a valid alternative in the treatment of severe subcutaneous emphysema following lung parenchyma resection.

Beck, PL, Heitman, SJ, Mody, CH (2002) Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema.Chest121,647-649. [PubMed] [CrossRef]
 
Leo, F, Solli, P, Veronesi, G, et al Efficacy of microdrainage in severe subcutaneous emphysema.Chest2002;122,1498-1499
 
Herlan, DB, Landreneau, RJ, Ferson, PF Massive spontaneous subcutaneous emphysema: acute management with infraclavicular “blow holes.”.Chest1992;102,503-505. [PubMed]
 

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References

Beck, PL, Heitman, SJ, Mody, CH (2002) Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema.Chest121,647-649. [PubMed] [CrossRef]
 
Leo, F, Solli, P, Veronesi, G, et al Efficacy of microdrainage in severe subcutaneous emphysema.Chest2002;122,1498-1499
 
Herlan, DB, Landreneau, RJ, Ferson, PF Massive spontaneous subcutaneous emphysema: acute management with infraclavicular “blow holes.”.Chest1992;102,503-505. [PubMed]
 
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