Pulmonary interstitial emphysema presenting in a woman on the intensive care unit: case report and review of literature

Abstract

IntroductionPulmonary interstitial emphysema is a life-threatening form of ventilator-induced lung injury. We present one of the few reported adult cases of pulmonary interstitial emphysema in a woman with respiratory failure admitted to our intensive care unit.Case presentationAn 87-year-old Caucasian woman with a diagnosis of community-acquired pneumonia was admitted to our intensive care unit requiring invasive ventilation. The combination of a poor oxygenation index and bilateral alveolar/interstitial infiltrates on a chest radiograph fulfilled the criteria for adult respiratory distress syndrome; the cause was thought to be a combination of the direct pneumonic pulmonary injury and extrapulmonary severe sepsis. By day seven, the fraction of inspired oxygen, peak airway and positive end expiratory pressures weaned sufficiently to allow an uncomplicated percutaneous tracheostomy. On day 10, problems with ventilation necessitated recruitment maneuvers with a Mapleson C circuit, after which dramatic surgical emphysema was noted. An upper airway bronchoscopy showed no obvious tracheal wall injury, and computed tomography of her chest showed extensive surgical emphysema, perivascular emphysema and peribronchial emphysema, which were consistent with a diagnosis of pulmonary interstitial emphysema. Over the following days, despite protective ventilatory strategies and intercostal tube thoracostomy, lung compliance along with oxygenation deteriorated and our patient died on day 14.ConclusionThe development of pulmonary interstitial emphysema is a rare but real risk when caring for patients with worsening lung compliance on the intensive care unit. Improved awareness of the condition, early protective ventilation strategies and timely treatment of any of the lethal complications will hopefully result in improved survival from the condition in adults.

Thoracic abnormal air collections in patients in the intensive care unit: radiograph findings correlated with CT

“…PIE is a potentially life-threatening condition wherein air collects in the pulmonary interstitium [16]. Although PIE commonly occurs in neonates but rarely in adults [16,49].…”

“…PIE is a potentially life-threatening condition wherein air collects in the pulmonary interstitium [16]. Although PIE commonly occurs in neonates but rarely in adults [16,49]. Greenough et al [50] reported that the incidence and mortality rates of PIE in preterm infants who required ventilation for respiratory distress syndrome (RDS) were 19.5% and 24%, respectively [50].…”

“…Greenough et al [50] reported that the incidence and mortality rates of PIE in preterm infants who required ventilation for respiratory distress syndrome (RDS) were 19.5% and 24%, respectively [50]. PIE is caused by air leakage due to alveolar rupture in barotrauma [49,51], and it is associated with intermittent positive pressure ventilation with peak airway pressures exceeding 30 cm H 2 O, severe ARDS, and pulmonary abnormalities, including pneumonia, coughing, chest trauma, and asthma [16,49,51]. The continued air leakage from the alveoli in patients with PIE leads to subpleural cysts, pneumomediastinum, IPL air collection, pneumothorax, and subcutaneous emphysema [49].…”

“…The main treatment is to achieve adequate oxygenation with a lower mean and peak airway pressure of ventilation [20]. Lateral decubitus positioning with the affected lung in the dependent position is also a useful treatment for localized disease [16,52], and selective main bronchial intubation of the unaffected side is useful for the unilateral disease [16,53]. PIE appears radiographically as lucent streaks that radiate from the hila to the periphery of the lung.…”

“…Pneumopericardium is treated by emergent pericardiocentesis in a case of cardiac tamponade [9]. The main treatment goal of pulmonary interstitial emphysema (PIE) is to achieve adequate oxygenation with a lower mean and peak airway pressure of ventilation [16]. Consequently, the detection and accurate localization of abnormal air collection is essential for early and optimal treatment and favorable patient outcomes.…”