Attending Anesthesiologist Intensivist Cleveland Clinic Foundation Cleveland, Ohio, United States
Introduction: Subcutaneous emphysema (SE), whether accompanying a severe pathologic disease state or as a benign symptom, often subsides with treatment of underlying cause. However, inclusion of cardiovascular compromise poses a difficult predicament for the intensivist. Although invasive procedures for treatment of subcutaneous emphysema are not widely employed, a procedure called "gills" has been shown to be effective in resolving progressive subcutaneous emphysema. The procedure involves making small incisions in the skin and subcutaneous tissue below the collarbone, which allows the trapped air to escape. We describe successful management of a patient with severe SE with “gills” procedure.
Description: A 62-year-old male with past medical history significant for severe COPD, aortic stenosis s/p aortic valve replacement, HIV and HTN presented to hospital with shortness of breath and was found to have a left sided pneumothorax and significant SE. Pneumothorax resolved with placement of chest tube and chest tube was removed after few days due to clinical improvement. However, the SE rapidly worsened the same day. SE was extensive and included chest, face, and eyes with progressive respiratory distress from airway compromise resulting in emergent intubation. The decision was immediately made to place bilateral infraclavicular gill slit incisions through the skin and subcutaneous tissue at the bedside with wound vac due to failure of the SE to resolve and persistent air leak from the pneumothorax. The gill slits relieved the tension in the SE, and the patient's ventilation immediately improved. The patient was extubated 4 days later without recurrence of SE. The patient required a chest tube placement due to persistence of the apical pneumothorax and was discharged home two weeks later after 7 endobronchial valves were placed
Discussion: In this case, subcutaneous emphysema (SE), developed after a pneumothorax and caused airway obstruction resulting in intubation. Gill slit incisions promoted air exit and pressure relief from the persistent apical pneumothorax with resolution of the SE. In the case of severe SE causing progressive respiratory compromise, infraclavicular gill slits are a viable option to allow pressure relief from resistant SE and improve respiratory function.
