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| ==Overview== | | ==[[Subcutaneous emphysema overview|Overview]]== |
| '''Subcutaneous emphysema''', sometimes abbreviated '''SCE''' or '''SE''' and also called '''tissue emphysema''', occurs when gas or air is present in the [[subcutaneous tissue|subcutaneous]] layer of the skin. ''Subcutaneous'' refers to the [[Tissue (biology)|tissue]] beneath the [[Cutis (anatomy)|cutis]] of the [[skin]], and ''[[emphysema]]'' refers to trapped air. Since the air generally comes from the [[chest cavity]], subcutaneous emphysema usually occurs on the chest, neck and face, where it is able to travel from the chest cavity along the [[fascia]].<ref name="pleural">
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| {{
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| cite book |editor=Bouros D |title=Pleural Disease (Lung Biology in Health and Disease) |publisher=Marcel Dekker |location=New York, N.Y |year=2004 |isbn=0-8247-4027-0 |oclc= |doi= |accessdate= 2008-05-16 |chapter=Pleural disease in the intensive care unit |author=Papiris SA, Roussos C |pages=771–777|url= http://books.google.com/books?id=PS8j3r31vWwC&pg=PA771&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=V8fQvguiH5tb-2xS6Sf8UnQGiGQ }}
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| </ref> Subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that has been described as similar to touching Rice Krispies;<ref name="Lefor02">
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| {{
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| cite book |author=Lefor, Alan T. |title=Critical Care on Call |publisher=Lange Medical Books/McGraw-Hill, Medical Publishing Division |location=New York |year=2002 |pages= |isbn=0-07-137345-4 |oclc= |doi= |accessdate=2008-05-09| pages=238–240 | url= http://books.google.com/books?id=6pvRaVggws8C&pg=PA238&dq=subcutaneous+emphysema&sig=nvI2yrrJ2DklEEyepNTk7euYVq4
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| }}
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| </ref> this sensation of air under the skin is known as ''subcutaneous crepitation''.
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| Subcutaneous emphysema can result from puncture of parts of the [[respiratory system|respiratory]] or [[gastrointestinal system]]s. Particularly in the [[thorax|chest]] and neck, air may become trapped as a result of [[penetrating trauma]] (e.g., [[gunshot wound]]s or stab wounds) or [[blunt trauma]]. [[Infection]] (e.g., [[gas gangrene]]) can cause gas to be trapped in the subcutaneous tissues. Subcutaneous emphysema can be caused by medical procedures and medical conditions that cause the pressure in the [[alveoli]] of the lung to be higher than that in the tissues outside of them.<ref name="Maunder84">
| | ==[[Subcutaneous emphysema historical perspective|Historical Perspective]]== |
| {{
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| cite journal |author=Maunder RJ, Pierson DJ, Hudson LD |title=Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management |journal=Arch. Intern. Med. |volume=144 |issue=7 |pages=1447–53 |year=1984 |month=July |pmid=6375617 |doi= |url=
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| }}
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| </ref> Its most common causes are [[pneumothorax]] and an improperly functioning [[chest tube]]. It can also occur spontaneously due to rupture of the alveoli, with dramatic signs.<ref name="Parker90">
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| {{
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| cite journal |author=Parker GS, Mosborg DA, Foley RW, Stiernberg CM |title=Spontaneous cervical and mediastinal emphysema |journal=Laryngoscope |volume=100 |issue=9 |pages=938–940 |year=1990 |month=September |pmid=2395401 |doi= |url=
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| }}
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| </ref> When the condition is caused by surgery it is called ''surgical emphysema''.<ref>
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| {{
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| cite book |author=|title=Oxford Concise Medical Dictionary |publisher=Oxford University Press |location=Oxford, UK |edition=6th |year=2003 |isbn=0-19-860753-9 |oclc= |doi= |accessdate=
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| }}
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| </ref> The term ''spontaneous subcutaneous emphysema'' is used when the cause is not clear.<ref name="Parker90"/>
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| Subcutaneous emphysema is not usually serious in and of itself, but the underlying causes, such as pneumothorax, can be.<ref name="Brooks98">
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| {{
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| cite book |author=Brooks DR |title=Current Review of Minimally Invasive Surgery |publisher=Current Medicine |location=Philadelphia |year=1998 |pages=36 |isbn=0-387-98338-4 |oclc= |doi= |accessdate=
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| }}
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| </ref> Although the underlying conditions require treatment, subcutaneous emphysema usually does not; small amounts of air are reabsorbed by the body. However, subcutaneous emphysema can be uncomfortable and may interfere with breathing, and is often treated by removing air from the tissues, for example by using a chest tube.
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| ==Symptoms and signs== | | ==[[Subcutaneous emphysema pathophysiology|Pathophysiology]]== |
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| [[Image:Subcutaneous emphysema chest arrow2.jpg|left|thumb|Bubbles of air in the subcutaneous tissue (arrow) feel like mobile nodules that move around easily.]] | | ==[[Subcutaneous emphysema causes|Causes]]== |
| Signs and symptoms of spontaneous subcutaneous emphysema vary based on the cause, but it is often associated with swelling of the neck and chest pain, and may also involve sore throat, neck pain, [[dysphagia|difficulty swallowing]], wheezing and [[dyspnea|difficulty breathing]].<ref name="Parker90"/> Chest [[X-ray]]s may show air in the [[mediastinum]], the middle of the chest cavity.<ref name="Parker90"/> A significant case of subcutaneous emphysema is easy to detect by [[palpation|touching]] the overlying skin; it feels like tissue paper or Rice Krispies.<ref name="Long95"/> Touching the bubbles causes them to move and sometimes make a crackling noise.<ref name="Brown04">
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| {{
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| cite book |author=DeGowin RL, LeBlond RF, Brown DR |title=DeGowin's Diagnostic Examination |publisher=McGraw-Hill Medical Pub. Division |location=New York |year=2004 |pages= 388, 552 |isbn=0-07-140923-8 |oclc= |doi= |accessdate= 2008-05-12 |url= http://books.google.com/books?id=6KUprj41xNIC&pg=PA552&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=QVoEhl9tFLvxIdakFZmEwoHD-94
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| }}
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| </ref> The air bubbles, which are painless and feel like small nodules to the touch, may burst when the skin above them is palpated.<ref name="Brown04"/> The tissues surrounding SCE are usually [[edema|swollen]]. When large amounts of air leak into the tissues, the face can swell considerably.<ref name="Long95"/> In cases of subcutaneous emphysema around the neck, there may be a feeling of fullness in the neck, and the sound of the voice may change.<ref name="NOAA91"/> If SCE is particularly extreme around the neck and chest, the swelling can interfere with breathing. The air can travel to many parts of the body, including the abdomen and limbs, because there are no separations in the [[adipose tissue|fatty tissue]] in the skin to prevent the air from moving.<ref name="Schnyder00">
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| {{
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| cite book |author=Schnyder P, Wintermark M |title=Radiology of Blunt Trauma of the Chest |publisher=Springer |location=Berlin |year=2000 |pages=10–11 |isbn=3-540-66217-0 |oclc= |doi= |accessdate= 2008-05-06 |url = http://books.google.com/books?id=Q4haCU0cX14C&pg=PA10&dq=subcutaneous+emphysema&lr=&sig=C7DbMJOQmB-m1YgW6qchCU4bDl0
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| }}
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| </ref>
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| ==Causes== | | ==[[Subcutaneous emphysema differential diagnosis|Differentiating Subcutaneous emphysema from other Diseases]]== |
| ===Trauma===
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| [[Image:Pulmonary contusion.jpg|thumb|left|A chest X-ray of a right sided [[pulmonary contusion]] associated with [[flail chest]] and subcutaneous emphysema]] | | ==[[Subcutaneous emphysema epidemiology and demographics|Epidemiology and Demographics]]== |
| Conditions that cause subcutaneous emphysema may result from both blunt and penetrating trauma;<ref name="Parker90"/> SCE is often the result of a stabbing or gunshot wound.<ref name="Peart06">
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| {{
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| cite journal |author=Peart O |title=Subcutaneous emphysema |journal=Radiologic Technology |volume=77 |issue=4 |pages=296 |year=2006 |pmid=16543482 |doi= |url=
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| }}
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| </ref>
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| [[Chest trauma]], a major cause of subcutaneous emphysema, can cause air to enter the skin of the chest wall from the neck or lung.<ref name="Brown04"/> When the [[pleura]]l membranes are punctured, as occurs in penetrating trauma of the chest, air may travel from the lung to the muscles and subcutaneous tissue of the chest wall.<ref name="Brown04"/> When the alveoli of the lung are ruptured, as occurs in [[pulmonary laceration]], air may travel beneath the [[visceral pleura]] (the membrane lining the lung), to the [[Hilum of lung|hilum of the lung]], up to the [[trachea]], to the neck and then to the chest wall.<ref name="Brown04"/> The condition may also occur when a [[rib fracture|fractured rib]] punctures a lung;<ref name="Brown04"/> in fact, 27% of patients who have rib fractures also have subcutaneous emphysema.<ref name="Schnyder00"/> Rib fractures may tear the [[parietal pleura]], the membrane lining the inside of chest wall, allowing air to escape into the subcutaneous tissues.<ref name="Wicky00">
| | ==[[Subcutaneous emphysema risk factors|Risk Factors]]== |
| {{
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| cite journal |author=Wicky S, Wintermark M, Schnyder P, Capasso P, Denys A |title=Imaging of blunt chest trauma |journal=European Radiology |volume=10 |issue=10 |pages=1524–1538 |year=2000 |pmid=11044920 |doi= |url=
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| }}
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| </ref>
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| Subcutaneous emphysema is a frequently found in pneumothorax (air outside of the lung in the chest cavity)<ref name="Hwang96">
| | ==[[Subcutaneous emphysema natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| {{
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| cite journal |author= Hwang JCF, Hanowell LH, Grande CM |title=Peri-operative concerns in thoracic trauma |journal= Baillière's Clinical Anaesthesiology |volume = 10 |issue = 1 |page=123–153 |doi= doi:10.1016/S0950-3501(96)80009-2 | date=1996
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| }}<!--No PMID found-->
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| </ref><ref name="Myers02">
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| {{
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| cite book |author=Myers JW, Neighbors M, Tannehill-Jones R |title=Principles of Pathophysiology and Emergency Medical Care |publisher=Delmar Thomson Learning |location=Albany, N.Y |year=2002 |pages=121 |isbn=0-7668-2548-5 |oclc= |doi= |accessdate=2008-06-16 |url = http://books.google.com/books?id=GgDdMkAZNPkC&pg=PA121&dq=%22sternal+fracture%22&lr=&client=firefox-a&sig=C7epwySocqqYZ5GNIG2en4knPrE
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| }}
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| </ref> and may also result from [[pneumomediastinum|air in the mediastinum]], [[pneumopericardium]] (air in the [[pericardial cavity]] around the heart).<ref name="Bonnett04"/> A [[tension pneumothorax]], in which air builds up in the [[pleural cavity]] and exerts pressure on the organs within the chest, makes it more likely that air will enter the subcutaneous tissues through pleura torn by a broken rib.<ref name="Wicky00"/> When subcutaneous emphysema results from pneumothorax, air may enter tissues including those of the face, neck, chest, armpits, or [[abdomen]].<ref name="pleural"/>
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| [[Image:Pneumothorax CT.jpg|left|thumb|A CT scan of a pneumothorax, one of the most common causes of subcutaneous emphysema]]
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| When subcutaneous emphysema occurs with pneumomediastinum, the condition is known as [[Hamman's syndrome]].<ref name="Jain08"/> Pneumomediastinum can result from a number of events. For example, foreign body [[Pulmonary aspiration|aspiration]], in which someone inhales an object, can cause pneumomediastinum (and lead to subcutaneous emphysema) by puncturing the airways or by increasing the pressure in the affected lung(s) enough to cause them to burst.<ref name="Findlay03">
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| {{
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| cite journal |author=Findlay CA, Morrissey S, Paton JY |title=Subcutaneous emphysema secondary to foreign-body aspiration |journal=Pediatric Pulmonology |volume=36 |issue=1 |pages=81–82 |year=2003 |month=July |pmid=12772230 |doi=10.1002/ppul.10295 |url=
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| }}
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| </ref>
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| Subcutaneous emphysema of the chest wall is commonly among the first signs to appear that [[barotrauma]], damage caused by excessive pressure, has occurred,<ref name="pleural"/><ref name="Criner02">
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| {{
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| cite book |author=Criner GJ, D'Alonzo GE |title=Critical Care Study Guide: text and review |publisher=Springer |location=Berlin |year=2002 |pages= 169 |isbn=0-387-95164-4 |oclc= |doi= |accessdate=2008-05-12 |url= http://books.google.com/books?id=pcHuRboVuXUC&pg=PA169&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=fy7fEDoBw3gz1C5JcvQ6o1ANzxY#PPA169,M1
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| }}
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| </ref> and it is an indication that the lung was subjected to significant barotrauma.<ref name="Rankine00">
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| {{
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| cite journal |author=Rankine JJ, Thomas AN, Fluechter D |title=Diagnosis of pneumothorax in critically ill adults |journal=Postgraduate Medical Journal |volume=76 |issue=897 |pages=399–404 |year=2000 |month=July |pmid=10878196 |doi= |url=http://pmj.bmjjournals.com/cgi/pmidlookup?view=long&pmid=10878196
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| }}
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| </ref> Thus the phenomenon may occur in diving injuries.<ref name="Parker90"/>
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| Trauma to parts of the respiratory system other than the lungs, such as rupture of a [[bronchial tube]], may also cause subcutaneous emphysema.<ref name="Wicky00"/> Air may travel upward to the neck from a pneumomediastinum that results from a bronchial rupture, or downward from a torn trachea or [[larynx]] into the soft tissues of the chest.<ref name="Wicky00"/> It may also occur with [[bone fracture|fractures]] of the [[facial bone]]s, [[neoplasm]]s, during [[asthma]] attacks, when the [[Heimlich maneuver]] is used, and during [[childbirth]].<ref name="Parker90"/> It is estimated to occur with pneumomediastinum in one in every 2000–100,000 deliveries.<ref name="Jain08">
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| {{
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| cite journal |author=Jain P, Vanner T |title=Subcutaneous emphysema with pneumomediastinum during the second stage of labour: A rare intrapartum complication |journal=The Internet Journal of Gynecology and Obstetrics |volume=9 |issue=1 |pages= |year=2008 |pmid= |doi= |url=http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijgo/vol9n1/emphysema.xml
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| }}
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| </ref> Injury with [[pneumatic tool]]s, those that are driven by air, is also known to cause subcutaneous emphysema, even in extremities (the arms and legs).<ref name="Molen99">{{cite journal |author=van der Molen AB, Birndorf M, Dzwierzynski WW, Sanger JR |title=Subcutaneous tissue emphysema of the hand secondary to noninfectious etiology: a report of two cases |journal=J Hand Surg [Am] |volume=24 |issue=3 |pages=638–41 |year=1999 |month=May |pmid=10357548 |doi= |url=}}</ref> It can also occur as a result of rupture of the [[esophagus]]; when it does, it is usually as a late sign.<ref name="pleural2">
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| {{
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| cite book |editor=Bouros D |title=Pleural Disease (Lung Biology in Health and Disease) |publisher=Marcel Dekker |location=New York, N.Y |year=2004 |isbn=0-8247-4027-0 |oclc= |doi= |accessdate= 2008-05-16 |chapter=Pleural disease in the intensive care unit| chapter=Pleural effusions in gastrointestinal tract diseases| author= Kosmas EN, Polychronopoulos VS |pages=798| url=
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| http://books.google.com/books?id=PS8j3r31vWwC&pg=PA771&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=V8fQvguiH5tb-2xS6Sf8UnQGiGQ
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| }}
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| </ref>
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| ===Medical treatment===
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| Subcutaneous emphysema is a common result of certain types of surgery; for example it is not unusual in [[thoracic surgery|chest surgery]].<ref name="Long95"> | |
| {{
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| cite book |author=Long BC Cassmeyer V, Phipps WJ|title=Adult Nursing: Nursing Process Approach |publisher=Mosby |location=St. Louis |year=1995 |pages=328 |isbn=0-7234-2004-1 |oclc= |doi= |accessdate= 2008-05-12 |url= http://books.google.com/books?id=7g9NirASUQsC&pg=PA328&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=heyGKZpNbSff_ybdIIN8KqTbC6s#PPA328,M1
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| }}
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| </ref> It may also occur from surgery around the esophagus, and is particularly likely in prolonged surgery.<ref name="Brooks98"/> Other potential causes are [[anesthesia]], in which its occurrence is frequently unexpected,<ref name="Pan89">
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| {{
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| cite journal |author=Pan PH |title=Perioperative subcutaneous emphysema: Review of differential diagnosis, complications, management, and anesthetic implications |journal=Journal of Clinical Anesthesia |volume=1 |issue=6 |pages=457–459 |year=1989 |pmid=2696508 |doi= |url=
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| }}
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| </ref> [[laparoscopy]],<ref name="Brooks98"/> and [[cricothyrotomy]]. In a [[pneumonectomy]], in which an entire lung is removed, the remaining bronchial stump may leak air, a rare but very serious condition that leads to progressive subcutaneous emphysema.<ref name="Long95"/> Air can leak out of the pleural space through an incision made for a [[thoracotomy]] to cause subcutaneous emphysema.<ref name="Long95"/> On infrequent occasions, the condition can result from [[dental]] surgery, usually due to use of high-speed tools that are air driven.<ref name="Monsour89">
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| {{
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| cite journal |author=Monsour PA, Savage NW |title=Cervicofacial emphysema following dental procedures |journal=Australian Dental Journal |volume=34 |issue=5 |pages=403–406 |year=1989 |month=October |pmid=2684113 |doi= |url=
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| }}
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| </ref> These cases result in usually painless swelling of the face and neck, with an immediate onset, the [[crepitus]] (crunching sound) typical of subcutaneous emphysema, and often with subcutaneous air visible on X-ray.<ref name="Monsour89"/>
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| One of the main causes of subcutaneous emphysema, along with pneumothorax, is an improperly functioning chest tube.<ref name="Lefor02"/> Thus subcutaneous emphysema is often a sign that something is wrong with a chest tube; it may be clogged, clamped, or out of place.<ref name="Lefor02"/> The tube may need to be replaced, or, when large amounts of air are leaking, a new tube may be added.<ref name="Lefor02"/>
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| Since [[mechanical ventilation]] can worsen a pneumothorax, it can force air into the tissues; when subcutaneous emphysema occurs in a ventilated patient, it is an indication that the ventilation may have caused a pneumothorax.<ref name="Lefor02"/> It is not unusual for subcutaneous emphysema to result from [[positive pressure ventilation]].<ref name="Conetta93"/> Another possible cause is a ruptured trachea.<ref name="Lefor02"/> The trachea may be injured by [[tracheostomy]] or [[intubation|endotracheal intubation]]; in cases of tracheal injury, large amounts of air can enter the subcutaneous space.<ref name="Lefor02"/> An [[endotracheal tube]] can puncture the trachea or bronchi and cause subcutaneous emphysema.<ref name="Peart06"/>
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| ===Infection===
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| Air can be trapped under the skin in [[necrotizing]] infections such as [[gangrene]], occurring as a late sign in gas gangrene,<ref name="Lefor02"/> of which it is the [[hallmark]] sign. Subcutaneous emphysema is also considered a hallmark of [[fournier gangrene]].<ref name="Levenson08">
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| {{
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| cite journal |author=Levenson RB, Singh AK, Novelline RA |title=Fournier gangrene: Role of imaging |journal=Radiographics |volume=28 |issue=2 |pages=519–528 |year=2008 |pmid=18349455 |doi=10.1148/rg.282075048 |url=
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| }}
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| </ref> Symptoms of subcutaneous emphysema can result when infectious organisms produce gas by [[fermentation]]. When emphysema occurs due to infection, signs that the [[infection]] is systemic, i.e. that it has spread beyond the initial location, are also present.<ref name="Brown04"/><ref name="Molen99"/>
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| ==Pathophysiology==
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| <!--image of fascia?-->
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| Air is able to travel to the soft tissues of the neck from the mediastinum and the [[retroperitoneum]] (the space behind the [[abdominal cavity]]) because these areas are connected by fascial planes.<ref name="Maunder84"/> From the punctured lungs or airways, the air travels up the [[perivascular cell|perivascular]] sheaths and into the mediastinum, from which it can enter the subcutaneous tissues.<ref name="Findlay03"/>
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| Spontaneous subcutaneous emphysema is thought to result from increased pressures in the lung that cause alveoli to rupture.<ref name="Parker90"/> In spontaneous subcutaneous emphysema, air travels from the ruptured alveoli into the [[interstitium]] and along the [[blood vessel]]s of the lung, into the mediastinum and from there into the tissues of the neck or head.<ref name="Parker90"/>
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| ==Diagnosis== | | ==Diagnosis== |
| | | [[Subcutaneous emphysema history and symptoms|History and Symptoms]] | [[Subcutaneous emphysema physical examination|Physical Examination]] | [[Subcutaneous emphysema laboratory findings|Laboratory Findings]] | [[Subcutaneous emphysema chest x ray|Chest X Ray]] | [[Subcutaneous emphysema CT|CT]] | [[Subcutaneous emphysema other imaging findings|Other Imaging Findings]] | [[Subcutaneous emphysema other diagnostic studies|Other Diagnostic Studies]] |
| [[Image:Subcutaneous emphysema pelvis arrows2.jpg|thumb|left|Subcutaneous air (arrows) can be seen as black areas on this pelvic CT scan.]] | |
| Significant cases of subcutaneous emphysema are easy to diagnose because of the characteristic signs of the condition.<ref name="pleural"/> In some cases, the signs are subtle, making diagnosis more difficult.<ref name="Wicky00"/> [[Medical imaging]] is used to diagnose the condition or confirm a diagnosis made using clinical signs. On a chest [[radiograph]], subcutaneous emphysema may be seen as radiolucent striations in the pattern expected from the [[pectoralis major]] muscle group. Air in the subcutaneous tissues may interfere with [[radiography]] of the chest, potentially obscuring serious conditions such as pneumothorax.<ref name="Criner02"/> It can also and reduce the effectiveness of chest [[ultrasound]].<ref name="Gravenstein07">
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| {{
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| cite book |author=Gravenstein N, Lobato E, Kirby RM |title=Complications in Anesthesiology |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2007 |pages= 171 |isbn=0-7817-8263-5 |oclc= |doi= |accessdate=2008-05-12 | url= http://books.google.com/books?id=S0usnJnJKjUC&pg=PA103&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=KX0AOaC9mzjPStAAFPN3LzmHk6w#PPA171,M1
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| }}
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| </ref> On the other hand, since subcutaneous emphysema may become apparent in [[chest X-ray]]s before a pneumothorax does, its presence may be used to infer that of the latter injury.<ref name="Wicky00"/> Subcutaneous emphysema can also be seen in [[Computerized tomography|CT scan]]s, with the air pockets appearing as dark areas. CT scanning is so sensitive that it commonly makes it possible to find the exact spot from which air is entering the soft tissues.<ref name="Wicky00"/>
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| ==Treatment== | | ==Treatment== |
| | [[Subcutaneous emphysema medical therapy|Medical Therapy]] | [[Subcutaneous emphysema surgery|Surgery]] | [[Subcutaneous emphysema primary prevention|Primary Prevention]] | [[Subcutaneous emphysema secondary prevention|Secondary Prevention]] | [[Subcutaneous emphysema cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Subcutaneous emphysema future or investigational therapies|Future or Investigational Therapies]] |
|
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| Subcutaneous emphysema is usually [[benign]].<ref name="pleural"/> Most of the time, SCE itself does not need treatment (though the conditions from which it results may); however, if the amount of air is large, it can interfere with breathing and be uncomfortable.<ref name="Abu-Omar95">
| | ==Case Studies== |
| {{
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| cite journal |author=Abu-Omar Y, Catarino PA |title=Progressive subcutaneous emphysema and respiratory arrest |journal=J R Soc Med |volume=95 |issue=2 |pages=90–91 |year=2002 |month=February |pmid=11823553 |doi= |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1279319
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| }}
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| </ref> Severe cases can compress the trachea and do require treatment.<ref name="Carpenito04">
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| {{
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| cite book |author=Carpenito-Moyet LJ |title=Nursing Care Plans and Documentation: Nursing Diagnoses and Collaborative Problems |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2004 |pages= 889 |isbn=0-7817-3906-3 |oclc= |doi= |accessdate= 2008-05-12 |url=http://books.google.com/books?id=Qyz8W5qS1dQC&pg=PA889&dq=subcutaneous+emphysema&lr=&client=firefox-a&sig=6d6W5YvFmUyN3z0Gch066nWoxQY#PPA889,M1
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| }}
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| </ref>
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| In severe cases of subcutaneous emphysema, [[catheter]]s can be placed in the subcutaneous tissue to release the air.<ref name="pleural"/> Small cuts, or "blow holes", may be made in the skin to release the gas.<ref name="Bonnett04">
| |
| {{
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| cite book |author=Grathwohl KW, Miller S |chapter= Anesthetic implications of minimally invasive urological surgery |editor= Bonnett R, Moore RG, Bishoff JT, Loenig S, Docimo SG |title=Minimally Invasive Urological Surgery |publisher=Taylor & Francis Group |location=London |year=2004 |pages= 105 |isbn=1-84184-170-6 |oclc= |doi= |accessdate=2008-05-11 |url= http://books.google.com/books?id=nU5WGRBeBBQC&pg=PA105&dq=subcutaneous+emphysema&client=firefox-a&sig=wajVVMwrwxWexK7G2DZYshGDxOU
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| }}
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| </ref> When subcutaneous emphysema occurs due to pneumothorax, a chest tube is frequently used to control the latter; this eliminates the source of the air entering the subcutaneous space.<ref name="Lefor02"/> If the volume of subcutaneous air is increasing, it may be that the chest tube is not removing air rapidly enough, so it may be replaced with a larger one.<ref name="Long95"/> Suction may also be applied to the tube to remove air faster.<ref name="Long95"/> The progression of the condition can be monitored by marking the boundaries with a special pencil for marking on skin.<ref name="Carpenito04"/>
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| Since treatment usually involves dealing with the underlying condition, cases of spontaneous subcutaneous emphysema may require nothing more than bed rest, medication to control pain, and perhaps supplemental oxygen.<ref name="Parker90"/> Breathing oxygen may help the body to absorb the subcutaneous air more quickly.<ref name="NOAA91">
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| {{
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| cite book |author=NOAA|title=NOAA Diving Manual |publisher=US Dept. of Commerce – National Oceanic and Atmospheric Administration |location= |year=1991 |isbn=0160359392 |oclc= |doi= |accessdate= 2008-05-09| pages=3.15 |url=http://books.google.com/books?id=MV55XeyatnwC&pg=PT47&dq=subcutaneous+emphysema&sig=nhUBUEP7DJTri6j1WqVE3jkTY2Y
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| }}
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| </ref> Reassurance and observation are also part of treatment.<ref name="Jain08"/>
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| ==Prognosis==
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| Air in subcutaneous tissue does not usually pose a lethal threat;<ref name="Maunder84"/> small amounts of air are reabsorbed by the body.<ref name="Long95"/> Once the pneumothorax or pneumomediastinum that causes the subcutaneous emphysema is resolved, with or without medical intervention, the subcutaneous emphysema will usually clear.<ref name="Criner02"/> However, spontaneous subcutaneous emphysema can, in rare cases, progress to a life-threatening condition,<ref name="Parker90"/> and subcutaneous emphysema due to mechanical ventilation may induce ventilatory failure.<ref name="Conetta93">
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| {{
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| cite journal |author=Conetta R, Barman AA, Iakovou C, Masakayan RJ |title=Acute ventilatory failure from massive subcutaneous emphysema |journal=Chest |volume=104 |issue=3 |pages=978–980 |year=1993 |month=September |pmid=8365332 |doi= |url=http://www.chestjournal.org/cgi/pmidlookup?view=long&pmid=8365332
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| }}<!--url works for full text-->
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| </ref>
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| ==History==
| | [[Subcutaneous emphysema case study one|Case #1]] |
| The first report of subcutaneous emphysema resulting from air in the mediastinum was made in 1850 in a patient who had been coughing violently.<ref name="Parker90"/> In 1900, the first recorded case of spontaneous subcutaneous emphysema was reported in a bugler for the Royal Marines who had had a tooth extracted: playing the instrument had forced air through the hole where the tooth had been and into the tissues of his face.<ref name="Parker90"/> Since then, another case of spontaneous subcutaneous emphysema was reported in a submariner for the US Navy who had had a root canal in the past; the increased pressure in the submarine forced air through it and into his face.<ref name="Parker90"/> The cause of spontaneous subcutaneous emphysema was clarified between 1939 and 1944 by Macklin, contributing to the current understanding of the [[pathophysiology]] of the condition.<ref name="Parker90"/>
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| ==See also== | | ==See also== |
| *[[Pulmonary toilet]] | | *[[Pulmonary toilet]] |
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| ==References==
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| {{reflist|2}}
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| {{Consequences of external causes}} | | {{Consequences of external causes}} |
