Management of Emphysematous Air in Ventilated Patients

Immediate Assessment and Diagnosis

The American College of Chest Physicians recommends verifying endotracheal tube position immediately by checking bilateral chest wall expansion, as auscultation is unreliable in critically ill patients, to prevent catastrophic deterioration 1, 2
The British Journal of Anaesthesia suggests obtaining urgent chest X-ray to confirm tube depth, identify pneumothorax, assess pneumomediastinum extent, and rule out inadvertent endobronchial intubation 1
The American Thoracic Society recommends performing lung ultrasound if there is any doubt about bilateral lung ventilation or pneumothorax, as it is superior to auscultation for detecting pneumothorax in intubated patients 1
The British Journal of Anaesthesia advises checking and documenting endotracheal tube depth at the teeth/lips, as difficult laryngoscopy is associated with inadvertent endobronchial intubation and traumatic intubation can cause air leak 2

The American College of Cardiology recommends reducing peak inspiratory pressures to the minimum levels consistent with adequate oxygenation and ventilation 1
The American Thoracic Society suggests minimizing positive end-expiratory pressure (PEEP) while maintaining acceptable oxygen saturation 1
The Anaesthesia journal recommends verifying endotracheal tube cuff pressure is maintained at 20-30 cmH2O to prevent air leak around the cuff, which can worsen subcutaneous emphysema 1, 3
The Circulation journal advises considering permissive hypercapnia if the patient can tolerate mild hypoventilation, as this reduces the risk of further barotrauma 4

The Circulation journal recommends using the DOPE mnemonic (tube Displacement, tube Obstruction, Pneumothorax, Equipment failure) when any intubated patient deteriorates acutely 4
The British Journal of Anaesthesia suggests inserting a chest tube immediately if tension pneumothorax is suspected based on hemodynamic instability, severe respiratory distress, or unilateral absent breath sounds 4
The British Journal of Anaesthesia advises performing fibreoptic bronchoscopy if there is concern for tracheal injury, as traumatic intubation can cause pharyngeal or oesophageal injury leading to deep infection and life-threatening sepsis 2

The British Journal of Anaesthesia recommends avoiding repeated intubation attempts in patients with suspected tracheal injury, as this increases trauma and worsens perforation 1, 5
The British Journal of Anaesthesia advises against using oxygen insufflation through airway exchange catheters except in extremis, as even low-flow oxygen administration via an airway exchange catheter risks catastrophic barotrauma if the catheter tip is placed or migrates beyond the carina 1, 5

The British Journal of Anaesthesia recommends maintaining humidification and regular tracheal suction using closed suction systems to reduce tube blockage and minimize aerosol generation 2, 6
The Anaesthesia journal advises checking cuff pressure and tube depth before and after any patient repositioning, including prone positioning, turning, nasogastric tube placement, or tracheal suction 6, 7
The British Journal of Anaesthesia suggests monitoring for signs of infection including fever, as pharyngeal or oesophageal injury may lead to mediastinitis requiring antibiotics 2

The British Journal of Anaesthesia recommends surgical consultation if persistent air leak despite optimal ventilator management suggests major airway injury 2
The British Journal of Anaesthesia advises urgent surgical assessment if suspected tracheal perforation from traumatic intubation 2