Case Study
A rapid response event was activated for a patient who appeared to be in acute distress. On arrival of the rapid response team, the patient was short of breath with visible swelling of the face. Per the bedside registered nurse, the patient was a 40-year-old male with a history of chronic obstructive pulmonary disease, admitted four days ago for right lower lobe pneumonia with a new right hilar mass. During the hospital course, he was seen by pulmonary and oncology teams, and bronchoscopy with ultrasound-guided biopsy of the mass was performed earlier in the day. In the last 4-5 h, the patient had become increasingly dyspneic and developed progressive swelling of the face, which had not improved with IV antihistamines and a dose of IV methylprednisolone.
Vital Signs
Temperature: 98.5 °F, axillary
Blood Pressure: 140/70 mmHg
Heart Rate: 110 beats per min (bpm)
Respiratory Rate: 30 breaths per min
Oxygen Saturation: 96% on room air
Focused Physical Examination
A quick exam showed a middle-aged male lying in bed in apparent distress; he was tachypneic but not using accessory muscles of respiration. Both lung fields were clear with equal air entry bilaterally. Facial swelling was noticed along with pitting with a crackling sensation under the skin. A crackling sensation was detected on the right side of the chest as well. The remaining physical examination was unremarkable.
Working Diagnosis
Subcutaneous emphysema, angioedema.
Interventions
A cardiac monitor and pads were attached. Stat chest X-ray and arterial blood gas were ordered. Chest X-ray was significant for subcutaneous air in the right chest wall and neck regions ( Fig. 32.1 ). Arterial blood gas was within normal limits. Based on available information, the most likely diagnosis was subcutaneous emphysema in the setting of a recent bronchoscopy procedure. Since the patient was saturating well on room air, did not require supplemental oxygen therapy, and was protecting his airway, he was retained on the current unit with a low threshold for intensive care unit (ICU) transfer.
Final Diagnosis
Subcutaneous emphysema as a complication of bronchoscopic procedure
Subcutaneous Emphysema
Subcutaneous emphysema is the infiltration of air into the subcutaneous tissue under the skin. Skin is comprised of two primary layers, namely the epidermis and dermis. Below the dermal layer lies the subcutaneous tissue, which is composed mainly of fascia and fatty tissue. The air in the subcutaneous tissue may indicate that some air is occupying another deeper area within the body, where it is not physiologically present. Such air/emphysema can expand to other compartments of the body and may lead to pneumomediastinum, pneumoretroperitoneum, and pneumothorax ( Fig. 32.2 ).
These patients can remain asymptomatic or present with sudden, painless soft tissue swelling with a predilection for the upper chest, neck, and face. Difficulty breathing is present occasionally.
Crepitations on skin palpation are pathognomonic of subcutaneous emphysema and are typically painless. If pneumomediastinum is present, then patients can present with precordial chest pain. Another typical finding in pneumomediastinum is the crackling sound with heartbeat (Hamman crunch). Patients with pneumothorax may present with pleuritic chest pain and shortness of breath. A few different causes of subcutaneous emphysema are reviewed in Table 32.1 .
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