Subcutaneous emphysema (SE) is defined as tumefaction produced by the presence of air or gas in the skin.1 It is a primarily aesthetic problem which does not usually cause complications, unless it is very extensive. We present a case of severe SE due to iatrogenic pneumothorax treated with a fenestrated angiocatheter, according to the method described by Beck,2 used for the first time in our centre.

A 77-year-old male, with a history of GOLD stage III COPD, was admitted for percutaneous pulmonary biopsy for the study of a lung nodule suggestive of bronchogenic carcinoma. After the procedure, pneumothorax was detected, requiring the placement of a drainage tube which was only maintained for 24h before it was accidentally removed. The patient subsequently developed extensive SE (face, neck, upper and lower limbs) and reappearance of the pneumothorax. A new drainage tube with aspiration was placed, resolving the pneumothorax, but not the SE. The decision was taken to withdraw the chest drainage and continue with conservative treatment. However, the SE progressed, causing dyspnoea and difficulty seeing and swallowing, so treatment was initiated with a fenestrated angiocatheter, according to the technique described by Beck,2 consisting of several fenestrations made in a spiral pattern along a 14G-calibre angiocatheter. Two fenestrated catheters were inserted in the subcutaneous space, 2cm lateral the midclavicular line at the level of the third rib (Fig. 1), achieving immediate improvement after placement. It was connected to continuous suction and the nursing staff and family members were instructed in performing massage manoeuvres from the distal to the medial regions to facilitate aspiration. In less than 48h, the patient could open his eyes and his dyspnoea had resolved. He was discharged after resolution of symptoms.

Fig. 1.

Severe subcutaneous emphysema. Fenestrated catheters placed according to the technique described by Beck, connected to continuous aspiration.

(0.1MB).

Studies on the mechanism of pulmonary interstitial emphysema, pneumomediastinum and SE have shown that air begins to migrate from a rupture in the alveoli to the pulmonary interstitial tissue and then on to the perivascular space until it reaches the mediastinum.2,3 When the passage of air is greater than the pleural resorption, SE occurs. This may also develop in the case of SE due to iatrogenic pneumothorax. Serious complications have been described, such as pacemaker malfunction, compromised airway, intracranial hypertension or respiratory failure, but these are uncommon. Conservative management is generally sufficient for the resolution of SE,1 although several therapies have been proposed, such as making holes in the skin, placement of chest tubes, pig-tail drainage or trocar drainage, all of which have limited use and are associated with risks of infection, scarring and patient discomfort.1,2 Fenestrated catheter placement is easy, fast and simple and is minimally invasive, since the risks of infection and skin scarring are reduced, although its use for periods longer than 72h is not recommended.4 This technique for the management of SE must be used on an individualised basis, depending on the clinical context and severity of the symptoms, although its ease of use, high effectiveness, low cost, minimal invasiveness and low risk of complications make it a good option in selected cases.