Disclosure(s): No relevant financial relationship(s) to disclose.
First Author: Mujtaba Abdellatif, MD Co-Author: Fatima Abuzaid, MD Co-Author: Omar Alkhateeb, MD – Resident Physician, Trinity Health Livonia Hospital Co-Author: Fatima Jamshaid, MBBS – Trinity Health Livonia Hospital Co-Author: Anukul Karn, MD – MD, Trinity Health Livonia Hospital
Introduction: Subcutaneous emphysema is a life-threatening complication of thoracic surgery, chest trauma, or lung pathology. It can occasionally progress to such an extent that it causes airway compromise, requiring advanced airway management and intensive care. This is a case of a patient with massive subcutaneous emphysema with facial distortion, airway compromise, and respiratory failure in a patient who had recently left AMA post-throacotomy and lobectomy.
Description: 66-year-old female with history of COPD and non-small cell lung cancer status post recent right thoracotomy and chest tube placement, who had presented to the ED with progressive facial swelling and difficulty breathing. Upon evaluation, she was gasping for air with profound facial, neck, chest, arm swelling. Patient was given two doses of epinephrine, Solu-Medrol, and Benadryl en route by EMS for suspected anaphylactic reaction as she was eating at the time of calling 911. She was noted to be in Afib with RVR (HR 170s). Imaging showed diffuse subcutaneous emphysema extending from the arms to the face and under the eyelids. She was alert but was intubated for airway protection and thoracic surgery was consulted. Patient underwent bilateral infraclavicular decompression incisions, resulting in gradual improvement in respiratory status. On review, she had recently left AMA on ICU day 2 from a different hospital post-thoracotomy and chest tube placement a week before. Her course was complicated by blow-hole cellulitis which was treated with antibiotics; she was extubated, her chest tube was removed and she left AMA after being transferred out of the ICU.
Discussion: This case highlights the critical manifestation of severe subcutaneous emphysema resulting in airway compromise and respiratory failure. The likely etiology was persistent air leak through a chest tube after thoracic surgery, compounded by premature discharge and patient noncompliance. It highlights the importance of early recognition and differentiation from anaphylaxis which may look similar (facial swelling, airway compromise) and prompt thoracic surgery consultation for decompression. Unlike many reported cases our patient survived and recovered without long-term sequelae though nonadherence and early AMA discharge remain risk factors for complications.
