Subcutaneous Emphysema Management in Intubated Patients
Ventilator Management and Tube Positioning
- The American Society of Anesthesiologists recommends ensuring proper tube depth is documented and verified with bilateral chest wall expansion, as auscultation is unreliable in critically ill patients 1, 2, 3, 4
- The Anaesthesia society suggests that bronchial intubation with the endotracheal tube cuff positioned too distally can cause localized barotrauma 1, 2
- Endotracheal tube cuff pressure should be maintained at 20-30 cmH2O to prevent air leak around the cuff, as recommended by the Anaesthesia society 1, 2, 3
Diagnostic Approach
- The Anaesthesia society recommends obtaining immediate chest x-ray to identify pneumothorax, pneumomediastinum, and extent of subcutaneous air 3, 4
- Lung ultrasound is superior to auscultation for detecting pneumothorax in intubated patients and should be performed if there is doubt about bilateral lung ventilation, according to the Anaesthesia society and the British Journal of Anaesthesia 3, 5
Management and Intervention
- The Anaesthesia society suggests reducing peak inspiratory pressures to minimum levels consistent with adequate oxygenation and ventilation 6
- Minimizing positive end-expiratory pressure (PEEP) while maintaining acceptable oxygen saturation is recommended by the Anaesthesia society 6
- The British Journal of Anaesthesia advises against repeated intubation attempts in patients with suspected tracheal injury, as this increases trauma and worsens perforation 7
- The Anaesthesia society recommends avoiding insufflation of oxygen through airway exchange catheters except in extremis, as this risks catastrophic barotrauma and worsening emphysema 8, 9