Diffuse Subcutaneous Emphysema Following Tracheal Perforation

Andrew Keenan, William Browne, Maneesh Bhargava

AJRCCM Articles in Press.

Published on 17-March-2017 as 10.1164/rccm.201611-2394IM

A 77-year-old woman without prior lung disease experienced a respiratory arrest at home requiring an emergency medical response. A King LT TM supraglottic airway was placed as endotracheal intubation was unsuccessful. She developed massive soft tissue swelling during transport to the emergency department. On physical examination the patient was unresponsive with marked swelling and crepitus of her face, neck, trunk, and extremities. Computed tomography of the chest, abdomen, and pelvis (Panels A and B) showed diffuse subcutaneous emphysema, pneumomediastinum, and left pneumothorax. An emergent tracheostomy was needed, and a posterior tracheal laceration was identified and repaired. Over two days, while being mechanically ventilated, the subcutaneous emphysema resolved without further interventions.

一名既往没有肺病病史的77岁女性患者在家中发生呼吸骤停。由于气管插管未成功，遂留置气管食管联合导管。患者转运到急诊科的途中发生了严重的软组织肿胀。体格检查发现，患者意识不清，面部、颈部、躯干和肢体都有明显的肿胀和捻发音。胸腹及盆腔CT（图A和B）显示弥漫性皮下气肿，纵隔积气及左侧气胸。行紧急气管切开，发现气管后壁裂伤并予修补。2天后，尽管患者接受了机械通气，但皮下气肿自行消失。

Alternative supraglottic airway devices such as a Combitube™ or a laryngeal mask airway can provide temporary airway support when a secure airway is required but endotracheal intubation is not feasible (1). The King LT TM is a supraglottic, single lumen, ventilation device consisting of two balloons with a single inflation port. (2). It cannot be used on a patient with an intact gag reflex, known esophageal disease or ingestion of caustic substances. While placement is often accomplished safely, insertion errors including over-inflation of the oropharyngeal balloon can occur, leading to tongue edema (3). The reported incidence of subcutaneous emphysema in patients transported to the emergency department with a King LT TM airway is 4% (4). Other described complications include vocal cord injury, esophageal trauma, and tracheal injury (4, 5). Diffuse subcutaneous emphysema occurs when air-containing structures rupture, allowing dissection of air into adjacent tissue planes. This is most often due to trauma but can be spontaneous. Subcutaneous emphysema generally reabsorbs without drainage after the underlying anatomic defect is corrected. However, subcutaneous drainage can be performed in patients with severe or life-threatening cases, often involving the eyes, face, and airway (6,7).

当需要建立人工气道但不能进行气管插管时，会厌上气道装置如气管食管联合导管或喉罩可以提供暂时性的气道支持。气管食管联合导管是一种会厌上、单腔通气装置，包括两个气囊及一个通气孔。呛咳反射良好、已知食道疾病或吞入腐蚀性物质的患者不应使用联合导管。尽管留置联合导管通常是安全的，但是也可以出现置管错误，包括口咽气囊过度充气导致舌水肿。留置联合导管后就诊于急诊科的患者中，皮下气肿的发生率为4%。报道的气管并发症还包括声带损伤、食道损伤及气管损伤。含气结构发生破坏后空气进入邻近组织，即可出线弥漫性皮下气肿。其常见原因为创伤，但也可为自发性。当解剖损伤得到纠正后，即使不进行引流，皮下气肿也能吸收。然而，在严重或致命性皮下气肿病例（常累及眼睛、面部及气道），往往需要进行皮下引流。