MD MUSC Health of Medical University of South Carolina, Georgia
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Introduction: Subcutaneous emphysema is oftentimes benign but in unique cases can cause life-threatening airway compromise when expansive. We report a rare case of a patient with severe Chronic obstructive pulmonary disease (COPD) and pneumothorax who developed massive subcutaneous emphysema with upper airway obstruction, requiring emergent Gil slit decompression and mechanical ventilation.
Description: A 50-year-old male with severe COPD, group 3 pulmonary hypertension, and bullous lung disease presented with acute dyspnea and pleuritic chest pain. Imaging performed identified a moderate right-sided pneumothorax. A pigtail catheter was placed, initially improving his symptoms temporarily. Within 12 hours, the patient decompensated with worsening dyspnea and new facial swelling thought secondary to catheter dislodgement. A large chest tube was attempted but initially malpositioned. Examination revealed extensive crepitus from the chest to the face. Repeat imaging verified severe subcutaneous emphysema and persistent pneumothorax. The patient developed voice changes, neck swelling, and hypercapnic respiratory failure with an arterial blood gas showing a pH of 7.21, and pCO₂ of 82. Emergent bilateral Gil slit incisions were performed, rapidly decompressing subcutaneous air with subsequent intubation for airway protection. A large-bore chest tube was successfully placed under imaging guidance. Over the following several days in the intensive care unit the patient's subcutaneous emphysema resolved, and he was weaned off the ventilator.
Discussion: This case demonstrates a unique but critical complication of pneumothorax in advanced COPD. While pigtail catheters are less invasive, they may be less effective in patients with large bullae and air leaks. Subcutaneous emphysema extending to the upper airway can rapidly disrupt anatomy and cause respiratory failure. Gil slit procedures, though rarely used, offer an effective temporizing measure for airway decompression and ultimately stabilization of the patient such as in this case which can be life-saving. This case highlights the importance of prompt airway assessment, multidisciplinary coordination, and familiarity with surgical decompression techniques in critical care.
