Case report: treatment of severe subcutaneous emphysema with a negative pressure wound therapy dressing

Abstract

Objective: This article describes a patient who developed severe subcutaneous emphysema and a persistent air leak after several attempts at needle thoracostomy for what was thought to be a tension pneumothorax. Subcutaneous emphysema was effectively treated with a topical negative pressure wound therapy dressing applied to a typical subfacial "blowhole" incision. This article aims to describe and contextualize the use of negative pressure wound therapy within the existing treatment options for subcutaneous emphysema.

Methods: A case report of the clinical course and technique was drafted, and the relevant literature in PubMed was reviewed.

Results: The level of subcutaneous emphysema decreased significantly within 48 hours of negative pressure wound therapy as confirmed with physical examination and computed tomography scans. Negative pressure wound therapy for subcutaneous emphysema has not been previously described in the literature.

Conclusions: Negative pressure wound therapy applied over subfascial incisions is a novel technique that effectively and rapidly controlled massive subcutaneous emphysema and persistent air leak. This technique may be efficacious in other cases of subcutaneous emphysema.

Figure 1

Portable roentogram obtained shortly after the acute onset of chest pain, tachypnea, and desaturation. Significant pneumothorax is evident (white arrow). Multiple attempts at needle decompression were performed without success prior to chest tube insertion.

Figure 2

Computed tomography imaging at the second intercostal space shortly after chest tube insertion demonstrating subcutaneous emphysema due to persistent air leak originating from sites of repeated needle thoracostomy attempts (white arrow). The air leak was exacerbated by high peak airway pressures required to maintain oxygenation and ventilation.

Figure 3

(a) Portable roentogram shortly after right tube thoracostomy following repeated unsuccessful attempts at needle thoracostomy demonstrates rapid development of extensive subcutaneous emphysema in conjunction with positive pressure ventilation and persistent chest tube air leak. (b) Computed tomography scout film approximately 12 hours after tube thoracostomy demonstrates wide extension and severe degree of subcutaneous emphysema (white arrows). Prepectoral “blowhole” incision (black arrow).

Figure 4

Portable roentogram demonstrates resolution of subcutaneous emphysema approximately 48 hours following application of topical negative pressure wound therapy dressing (white arrow).

Figure 5

Representative saggital computed tomography scan images of the chest at the level of the sternoclavicular joint (a) and the top of the aortic arch (b)taken shortly after tube thoracostomy. Note the extensive bilateral subcutaneous emphysema. Corresponding sections after 48 hours of NPWT (c, d, respectively) demonstrate near-complete resolution of SE.