CASE REPORT
Buried in Trapped Air: Tension Pneumothorax.
Massive Subcutaneous Emphysema and the Battle for Airway Control Parul Issar* Yatharth Superspeciality Hospital.
Greater Noida.
India.
*Corresponding Author:
Parul Issar.
MD.
Yatharth Superspeciality Hospital.
Sehdeo Hospital.
Block A.
Ansal Golf Links 1.
Greater Noida.
Uttar Pradesh 201315.
India.
Email: parulissar@gmail.
ABSTRACT
Primary Spontaneous Tension pneumothorax (STP) is a life-threatening medical emergency.
The presence of extensive subcutaneous emphysema (SCE) can further aggravate the respiratory distress and make the airway management even more challenging in the ER.
The situation can become even worse when such a patient needs cardiopulmonary resuscitation on arrival.
We report an unusual case of a 55-year-old man who presented in the ER with a history of sudden onset of respiratory distress while taking a bath.
The patient was brought to the ER in a state of gasping, hypoxia, with swelling over the face and chest, and shock.
We made a clinical diagnosis of tension pneumothorax (TP), and bilateral needle decompression of the pneumothoraces was done.
But it was not sufficient, and he landed in cardiac arrest.
The CPR and the airway management were extremely difficult due to airway edema.
He was quickly tracheostomised in the ER, and a surgical airway saved his life.
Primary spontaneous pneumothorax is an uncommon condition, but it can rarely end up in tension pneumothorax, and accompanying subcutaneous emphysema can make the management further challenging.
Airway skills of the ER team are important in saving such patientsAo lives.
Keywords: Tension pneumothorax, massive subcutaneous emphysema.
CPR, difficult intubation.
INTRODUCTION
Primary Spontaneous Tension pneumothorax (STP) is a life-threatening TP presenting without any known lung disease.
It can be managed with emergency needle decompression and other supportive treatment.
1 Few patients with TP may also have massive accumulation of air in deep tissues of the neck (SCE), compromising airway and venous return.
2 Airway management in such patients can be very challenging.
Our patient in discussion here had a similar life-threatening combination of STP and severe extensive SCE.
He was a 55-year-old man who developed cardiac arrest due to tension pneumothorax (TP) and extensive subcutaneous emphysema (SCE).
During the CPR, the patient was in a Aucannot intubate, cannot ventilateAy (CICO) situation.
An emergency percutaneous tracheostomy was done, and ROSC was finally achieved.
It is a rare combination of life-threatening primary SPT and severe SCE successfully managed with surgical Front of the Neck Airway (FONA).
CASE ILLUSTRATION
A 55-year-old male patient with no past medical and surgical history presented in the ER with an acute onset of breathing difficulty of around 2 hours duration, followed by swelling over the neck, chest, and face.
Dyspnoea soon progressed to distress with difficulty in speaking and swallowing.
He was a heavy smoker.
Acta Med Indones - Indones J Intern Med A Vol 57 A Number 3 A July 2025 Vol 57 A Number 3 A July 2025 Quick clinical examination showed the patient was afebrile, drowsy, restless, dyspnoeic, and gasping for air.
His heart rate was 156 beats per minute.
NIBP was 65/43 mmHg, and oxygen saturation was 67% on room air at the time of He had subcutaneous emphysema all over his face, neck, anterior chest, and whole abdomen (Figures 1 and .
On auscultation, there was crepitus all over the chest and abdomen.
A clinical diagnosis of primary SPT with massive SCE was made.
Oxygen support, fluid resuscitation, and inotropes were initiated with simultaneous emergency needle decompression of bilateral hemithoraces in the 5th intercostal space in the anterior axillary line.
SpO2 levels improved to 81% but his respiratory distress Soon, the patient became cyanotic, unresponsive, and pulseless.
Cardiopulmonary resuscitation (CPR) was immediately started.
Bag-mask ventilation during the CPR was not effective due to the severe upper airway Oral and nasopharyngeal airways also failed to improve the ventilation.
An attempt at orotracheal intubation was made, but due to extreme emphysema of the upper airway, laryngoscopy failed.
Rescue airway with SAD was the next step.
Proseal LMA was inserted, and finally.
ROSC was achieved.
But due to extensive chest wall emphysema and perhaps air infiltration around the glottis, ventilation was still inadequate, and target EtCO2 and SpO2 levels could not be attained.
Hoping for a better decompression of pneumothoraces, bilateral intercostal drainage tubes were inserted and connected to the underwater seal.
But this also did not improve the ventilation.
Video laryngoscopy was tried, which showed excessive infiltration of air in the glottic structures, leaving an extremely narrowed glottic chink.
Further attempts for intubation were therefore deferred, and a plan for an elective tracheostomy was To continue ventilation.
Proseal LMA was reinserted, but unfortunately, this time it didnAot fit well, and air started leaking, perhaps due to progressively increasing airway emphysema and high airway pressures.
Consequently.
SpO2 levels started dropping rapidly.
It was a CICO situation with impending cardiac arrest.
emergency percutaneous tracheostomy was done Buried in Trapped Air: Tension Pneumothorax in the ER with the Seldinger technique.
A size 7.
mm ID tracheostomy tube was inserted, and bag ventilation was established.
SpO2 levels quickly improved to >90%.
The time taken to secure the airway was not more than 90 seconds.
The patient was then shifted to the Intensive Care Unit for further management.
CT scan of his thorax showed bilateral pneumothoraxes with emphysematous lungs and multiple bullae with extensive subcutaneous emphysema extending from the neck above to the thighs below (Figures 3,4,.
Upper airway structures Figure 1.
Extensive subcutaneous emphysema over the face and the eyelids at the time of admission Figure1-2.
Percutaneous Percutaneous tracheostomy tube intube situ in situ Figure Parul Issar Acta Med Indones-Indones J Intern Med Figure 3.
CT thorax showing extensive air collection between the layers of the chest Bilateral pneumothoraces with right mediastinal shift Figure 4.
Bilateral Intercostal drainage tubes in place Vol 57 A Number 3 A July 2025 Buried in Trapped Air: Tension Pneumothorax Figure 5.
Bullous emphysematous changes are visible in both lungs Figure 6.
Completely resolved subcutaneous emphysema.
Post tracheal decannulation were also emphysematous.
The patient was discharged home in a stable condition without any neurological deficit after bilateral pleurodesis (Figure .
DISCUSSION