Improvement of Chest Wall Compliance Immediately Following Subcutaneous Placement of Central Venous Catheter for Decompression of Massive Subcutaneous Emphysema
Subcutaneous emphysema (SE) and pneumomediastinum occur frequently in association with trauma, soft tissue infection, chest tube placement, esophageal rupture, cardiothoracic surgery, and positive pressure ventilation. While typically benign and self limiting, rarely and unpredictably, rapid accumulation of gas can progress to a state of physiologic compromise requiring prompt intervention; a clinical entity known as massive subcutaneous emphysema (MSE) MSE can lead to compartment syndrome, obstructive shock, skin necrosis, large airway compression, pulmonary barotrauma, and patient discomfort. We report the case of a mechanically ventilated 58 year old woman who developed decreased chest wall compliance and impaired ventilator mechanics from MSE, requiring emergent decompression. While various methods for decompression have been described in the literature, no single method has been established as most effective. Rapid placement of a central venous catheter into the subcutaneous tissue of the anterior chest wall, attached to suction produced dramatic improvement of tissue swelling, ventilatory peak and plateau pressures, and both dynamic and static compliance. We propose a novel approach for decompression that is quick, minimally invasive, readily accessible, and familiar to clinicians practicing in an intensive care unit or emergency department.