In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction onin situchest drain?: Table 1:

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain?'. Altogether more than 200 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Subcutaneous emphysema is usually a benign, self-limiting condition only requiring conservative management. Interventions are useful in the context of severe patient discomfort, respiratory distress or persistent air leak. In the absence of any comparative study, it is not possible to choose definitively between infraclavicular incisions, drain insertion and increasing suction on an in situ drain as the best method for managing severe subcutaneous emphysema. All the three techniques described have been shown to provide effective relief. Increasing suction on a chest tube already in situ provided rapid relief in patients developing SE following pulmonary resection. A retrospective study showed resolution in 66%, increasing to 98% in those who underwent video-assisted thoracic surgery with identification and closure of the leak. Insertion of a drain into the subcutaneous tissue also provided rapid sustained relief. Several studies aided drainage by using regular compressive massage. Infraclavicular incisions were also shown to provide rapid relief, but were noted to be more invasive and carried the potential for cosmetic defect. No major complications were illustrated.

Death following a Massive Subcutaneous Emphysema

“…A review of the literature suggests that death from subcutaneous emphysema is extremely rare, with the few reported deaths occurring in the context of pneumothorax. In particular Johnson, et al [3] reviewed several cases of subcutaneous emphysema, including the management techniques used, and the subsequent outcomes. No deaths were reported following management of these patients.…”

Recalcitrant Subcutaneous Emphysema: A Solution with A Simple Method

“…There are many different types of drains that have been used for patients with recalcitrant SE, which have been reported in the literature (4). The differences between them may seem subtle, but they may result in clinical differences for the patients.…”

“…Several methods have been used to resolve recalcitrant SE, such as performing infraclavicular incisions, inserting subcutaneous drains with different materials, and increasing suction on a chest tube (4). All these methods have resolved SE in most cases, but vary in the level of aggressiveness and difficulty in their performance.…”

Massive subcutaneous emphysema after traumatic pneumothorax

“…A wait‐and‐see strategy is advised in patients with limited subcutaneous emphysema, whereas additional drainage may contribute to faster patient relief. All in all, such interventions must be tailored on an individual basis …”