Efficacy of microdrainage in severe subcutaneous emphysema – Letter to the Editor
Francesco Leo
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 complications. (1-3)
At the European Institute of Oncology (IEO), since 1998 we have routinely used the substaneous drainage of emphysema by manually fenestrated angiocathethers, 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 [less than or equal to] 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.
Francesco Leo, MD, FCCP
Piergiorgio Solli, MD
Giulia Veronesi, MD
Lorenzo Spaggiari, MD, PhD, FCCP
Ugo Pastorino, MD
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
REFERENCES
(1) Herlan DB, Landrenau RJ, Ferson PS. Massive spontaneous subcutaneous emphysema: acute management with infraclavicular “blow holes.” Chest 1992; 102:503-505
(2) 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
(3) Kelly MC, McGuigan JA, Allen RW. Relief of tension subcutaneous emphysema using a large bore subcutaneous drain. Anaesthesia 1995; 50:1077-1079
(4) Beck PL, Heitman SJ, Mody CH. Simple construction of a subcutaneous catheter for treatment of severe subcutaneous emphysema. Chest 2002; 121:647-649
COPYRIGHT 2002 American College of Chest Physicians
COPYRIGHT 2003 Gale Group
