Subcutaneous emphysema of the chest, neck, face, lungs

If air bubbles accumulate in the subcutaneous fat tissue, then we speak of such a pathology as subcutaneous emphysema. Emphysema usually appears against the background of other diseases - for example, when the respiratory organs or esophagus are affected.

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Epidemiology

The word "emphysema" literally means "swelling" and was first used by Hippocrates to describe the natural accumulation of gas bubbles in tissues.

Subcutaneous emphysema was also described by the Dutch doctor Herman Boerhaave in the 18th century. The symptom was related to a spontaneous rupture of the esophagus, resulting in the formation of blisters under the skin.

A more detailed description of the pathology was given by Dr. Laennec in the 19th century.

There are no exact statistics on the disease. There is data that during laparoscopic access, subcutaneous emphysema, as a complication, occurs in 0.4-2.3% of cases.

Subcutaneous emphysema may also develop as a result of dental procedures involving instruments that operate under high pressure.

The appearance of subcutaneous emphysema is possible in patients with tension spontaneous pneumothorax: such a diagnosis is established relatively often, for example, 4-15 patients per hundred thousand of the population.

Closed chest trauma can lead to subcutaneous emphysema in approximately every second victim. Open trauma is complicated by emphysema in 18% of cases.

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Causes subcutaneous emphysema

The formation of subcutaneous emphysema is possible with the following diseases and conditions:

• spontaneous pneumothorax with damage to the parietal pleura;
• ruptured lung due to rib fracture;
• penetrating chest wound;
• rupture of the trachea, bronchus or esophagus.

Subcutaneous emphysema can develop after some dental procedures, as well as after tracheostomy, laparoscopic access.

A limited version of emphysema can occur with joint damage, fractures of the facial bones, and damage to the mucous tissues of the nose.

The subcutaneous tissue can fill with air when the chest, respiratory organs, or esophagus are injured.

Perhaps, most often, subcutaneous emphysema in the chest occurs as a result of a rib fracture, as this is the most common chest injury. In old age, such fractures are especially common, which is explained by the age-related decrease in the elasticity of the bone apparatus. Subcutaneous emphysema with a rib fracture is formed when the lung is damaged and air penetrates into the subcutaneous tissue. If the intercostal vessels are damaged, then profuse hemorrhage into the pleural cavity or into soft tissues may occur.

In some cases, subcutaneous emphysema occurs after laparoscopy. To understand why this happens, it is necessary to delve into the specifics of this operation. Before inserting the laparoscope, the patient's abdominal cavity is filled with carbon dioxide - to facilitate the advancement of instruments and the isolation of organs. The most common place for subcutaneous emphysema to appear in this case is the puncture through which the gas is injected: it can get into the fatty tissue that lies directly under the skin. There is nothing scary about this: such emphysema disappears on its own in a couple of days.

Subcutaneous emphysema after tooth extraction is considered a rare complication, but its development cannot be ruled out. The use of instruments with air pressure on the gum margin contributes to the development of emphysema, especially in the presence of a periodontal pocket or when the gum does not fit tightly. If the patient's gum fits the tooth completely, then the development of such a complication is almost impossible. In the vast majority of cases, subcutaneous emphysema after tooth extraction is not complicated by infection and goes away on its own. But many dentists prescribe antibiotics as a preventive measure.

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Risk factors

The following factors can accelerate the development of emphysema:

• congenital anomalies of the respiratory system;
• chest shape disturbance after injury;
• closed rib fracture with pulmonary penetration;
• chronic pulmonary intoxication;
• any penetrating wounds to the chest;
• purulent infections;
• bruises and closed chest injuries;
• tumors of the chest and neck;
• dental procedures using high pressure devices;
• chronic long-term smoking, chronic bronchitis;
• pulmonary barotrauma;
• joint injuries;
• Artificial ventilation, use of endotracheal tube.

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Pathogenesis

Subcutaneous emphysema is formed as a result of some defect in the parietal pleura, when air enters the tissue during spontaneous pneumothorax.

Pneumothorax is the result of a lung injury that occurs with a rupture of the pleura and the entry of air into the near-lung space.

When a pleural rupture occurs, the lung collapses and breathing capacity is impaired. The volume of air increases with each breath, which leads to increased pressure in the pleural cavity.

The damaged outer pleural membrane allows air to pass through, which penetrates deep into the tissue and accumulates in the subcutaneous tissue, after which it disperses along the paths of least resistance.

Another variant of emphysema development: air penetrates the tissues from the outside – for example, during a wound or an open fracture of the chest. In such a situation, pneumothorax does not develop, and the emphysema itself is strictly localized.

Pneumothorax may also be absent when the pleural cavity is blocked by damaging rib fractures. In such patients, subcutaneous emphysema is formed when air enters from the mediastinum through the upper opening of the osteochondral thoracic skeleton, through which the esophagus and trachea pass.

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Symptoms subcutaneous emphysema

Subcutaneous emphysema occurs in the area of a joint or chest. Air can then be forced out and spread throughout the body. Typically, the direction of such spread is upward toward the head or downward toward the groin area.

The first signs of the development of subcutaneous emphysema are a visible, identifiable tumor, which, when pressed, produces a typical crunching sound called crepitus.

Emphysema itself does not directly threaten human life. However, theoretically, the tumor can exert slight pressure on nearby vessels, which affects the patient's condition. In severe cases, other symptoms are added:

• cardiac dysfunction;
• chest pain;
• arrhythmia;
• blood pressure instability.

If subcutaneous emphysema was a consequence of pneumothorax, then additional symptoms may include respiratory distress, shortness of breath, and wheezing.

If emphysema is the result of a chest injury or wound, symptoms consistent with the injury will be present.

Subcutaneous emphysema on the right or left side of the chest is often characterized by symptoms that can have varying degrees of severity:

• progressive shortness of breath with difficulty exhaling;
• redness of the face during coughing;
• bulging of the veins of the neck due to increased intrathoracic pressure;
• bluish tint of the tip of the nose and nails as a result of oxygen starvation.

With long-standing emphysema, liver function may be impaired.

Extensive, growing subcutaneous emphysema is always visible to the naked eye: a large volume of air under the skin can accumulate in different parts of the body, including the limbs, in the abdominal area, etc. The tumor itself does not cause pain to the patient. Painful symptoms can only be associated with the initial cause of the development of subcutaneous emphysema.

Stages

The spread of subcutaneous emphysema occurs in stages:

1. A limited stage in which only a small area is involved in the pathological process, and the vesicle is determined only by palpation.
2. A common stage when air accumulation can be found not only directly in the affected area, but also above and below it.
3. Total stage, which is characterized by massive air distribution. This condition is considered threatening and occurs in such complex pathologies as damage to the lobar bronchi or valve pneumothorax.

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Forms

Based on the origin of subcutaneous emphysema, the following types of this pathology can be distinguished:

• post-traumatic – formed as a result of open or closed traumatic injury to the chest;
• iatrogenic – occurs as a complication after certain medical procedures (for example, this is considered possible after endoscopy and some dental procedures).

The most likely locations of subcutaneous emphysema

• Subcutaneous emphysema of the chest is not a disease, as many believe, but only a symptom that develops as a result of trauma to the respiratory tract or esophagus, rib fractures, and also as a result of endoscopic interventions. Air from the subcutaneous space of the chest can move to the head and neck area, or lower - to the groin and femoral area.
• Subcutaneous emphysema of the neck often occurs during complex tooth extraction procedures or after the use of high-speed handpieces and syringes that supply air under pressure for manipulations in the oral cavity. In these cases, certain volumes of air enter under the skin through the gingival sulcus.
• Subcutaneous emphysema of the face is typical for fractures of the facial bones, fractures of the nasal sinuses, closed cracks. As a rule, air penetrates into the tissues of the eyelids, as well as into the orbit of the eyes. Less often, such a phenomenon is observed with damage to the mucous tissues of the nasal cavity.

Subcutaneous air accumulation on the face can spread to the mediastinal region.

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Complications and consequences

Usually, if the cause of subcutaneous emphysema is eliminated, it disappears on its own within a few days.

In other cases, emphysema can cause a number of adverse effects:

• increased blood pressure in the pulmonary circulation, pulmonary heart disease;
• increased intrapulmonary pressure, heart failure;
• hypoxemia (decreased oxygen levels in the blood), hypoxia (decreased oxygen levels in tissues);
• paraseptal type of emphysema, occurring with destruction of the alveolar membranes;
• pneumosclerosis;
• hemorrhages in the lungs;
• addition of a secondary infectious disease.

The emphysema tumor should not be warmed up or kneaded. This can lead to further air movement through the body.

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Diagnostics subcutaneous emphysema

The diagnosis is made taking into account the following points:

• information about the medical history (details of the period preceding the onset of emphysema are taken into account);
• examination with palpation of the location of air under the skin (subcutaneous emphysema is characterized by the absence of pain, asymmetry and the presence of crunching);
• results of additional studies.
• Laboratory tests include a complete blood count. The following changes are characteristic of emphysema:
• increased red blood cell count;
• increase in hemoglobin levels;
• increase in hematocrit by more than 47%;
• decrease in ESR;
• blood thickening.

Instrumental diagnostics typically consists of the following procedures:

1. The X-ray examination is performed in a standard projection using a survey image.
2. Magnetic resonance imaging of the lungs is done to assess the condition of the large bronchi, lymphoid tissue and lungs.
3. Computed tomography is performed to obtain a detailed layer-by-layer image of the structure of the lungs.
4. Lung scintigraphy involves the introduction of labeled radioactive isotopes into the respiratory system and the acquisition of images using a gamma camera. Scintigraphy helps detect vascular abnormalities caused by emphysema.

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Differential diagnosis

Differential diagnostics is mandatory, as there are other pathologies that can cause an increase in volume. Such pathologies primarily include hematomas (accumulation of blood in tissues), allergic reactions and Quincke's edema.

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Treatment subcutaneous emphysema

Since subcutaneous emphysema resolves on its own without any medical intervention, treatment is aimed only at eliminating the direct causes of its occurrence.

If emphysema was caused by pneumothorax, the doctor will use a puncture to pump air out of the pleural cavity. If this procedure is ineffective, it means that air continues to flow from the lung tissue: it is necessary to create a hermetic drainage of the pleural cavity, or install an active suction system - for example, using an electrovacuum device.

In cases where the above methods do not produce the expected results, surgical treatment is performed. For example, in the case of a chest injury, thoracotomy and suturing of the injury are performed.

To improve the general condition of the patient, the following medications are prescribed:

Painkillers
Ketolong, Analgin, Sedalgin	Take one tablet twice daily for chest pain.
Glucocorticosteroid drugs
Prednisolone, Dexamethasone	To prevent and treat inflammation, take 1 tablet twice a day.
Vitamins
Undevit, Revit, Decamevit	Take one pill or tablet 2-3 times a day to strengthen the immune system.
Antibiotics
Ceftriaxone, Ofloxacin, Amoxil	Prescribed when an infectious complication occurs or when signs of inflammation increase
Cough remedies
Libexin, Ambroxol, Flavamed	Take one tablet up to three times daily to relieve cough and expectoration.

When prescribing a particular drug, the likelihood of side effects must be taken into account. Before starting treatment, you should carefully read the instructions for each of the prescribed drugs.

Physiotherapy treatment

To prevent negative consequences of subcutaneous emphysema, it is recommended to do breathing exercises, which will help improve oxygen exchange and air circulation in the lungs. The patient needs to take deep breaths for fifteen minutes, then try to hold the exhalation, exhaling gradually. This exercise should be practiced every day, 4 times a day.

Breathing exercises will help restore the function of the bronchi and alveoli, which provide the gas exchange process.

Physical activity for patients with subcutaneous emphysema should be temporarily limited.

It is recommended to systematically massage the chest area, avoiding the air accumulation zone, which is strictly forbidden to massage. Therapeutic chest massage will help to avoid congestion in the lungs.

Folk remedies

• It is advisable to drink 50 ml of fresh potato juice every day, morning, afternoon and evening, this will have a positive effect on the oxygen exchange in the tissues.
• For several months, you need to systematically consume honey - a tablespoon up to three times a day. This will strengthen the immune system and prevent the development of the inflammatory process.
• You should include walnuts in your menu: to improve your well-being, it is enough to eat 1-2 nuts daily.
• When brewing tea, it is useful to add lemon balm or dried plantain leaves to it.
• It is useful to do warm pine inhalations every day.

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Herbal treatment

Treatment of subcutaneous emphysema caused by damage to the respiratory or digestive organs is a rather complex and multifaceted process, the main goal of which is to restore the function of damaged systems.

As a supplement to the main treatment, you can agree with your doctor on the use of the following herbal folk recipes:

• Prepare an infusion from equal parts of juniper berries, birch leaves and dandelion rhizome. Take 200 ml twice a day half an hour before meals.
• Tea is prepared from equal parts of birch leaves and horsetail grass. Drink 150 ml three times a day, before meals.
• An infusion is prepared from the following plants: 10 g fennel seeds, 10 g elderflower, 10 g caraway seeds, 10 g adonis, 30 g parsley seeds, 30 g juniper berries. One glass of the infusion is drunk three times during the day.
• Prepare tea from 50 g of birch leaves, 20 g of rose hips and 20 g of field horsetail rhizome. Drink a third of a glass, up to four times a day, half an hour before meals.

Homeopathy

Treatment of complex cases of subcutaneous emphysema can be supplemented with the use of homeopathy:

• Lobelia 3x, 3 - for shortness of breath that accompanies pulmonary emphysema;
• Tartarus emeticus 3, 6 – for bubbling and wheezing, with impaired lung tone;
• Ipecacuanha 3 - for chest cramps;
• Antimonium arsenicosum 3, 6 for heart failure and bronchitis;
• Carbo vegetabilis 3x, 3, 6 – for severe atrophic changes in the lungs;
• Curare 3, 6 – for severe respiratory distress.

Homeopathic medicines are prescribed by a special homeopathic doctor, who selects them individually.

Such products are distinguished by the absence of contraindications and side effects; only occasionally can the drugs cause allergies.

Prevention

The following are considered necessary preventive measures to prevent subcutaneous emphysema:

• Timely visit to the doctor for any pathologies of the respiratory system.
• Conducting a regular full course of treatment for chronic respiratory diseases.
• Providing protection in chronic and acute intoxications of the respiratory tract.
• Strengthening the body's defenses, hardening, active lifestyle.
• Getting rid of smoking.
• Preventing chest trauma.
• Periodic trips to the sea or forest: fresh clean air (especially sea or pine air) helps to clear the respiratory tract and improve the health of the body as a whole.

To prevent any form of subcutaneous emphysema, it is necessary to prevent the occurrence of causes that contribute to the development of the disease.

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Forecast

The prognosis is considered favorable provided that the underlying cause of subcutaneous emphysema is eliminated. To speed up the recovery process, it is necessary to adhere to the following recommendations:

• quit smoking forever;
• prevent the development of infectious diseases;
• spend more time outdoors;
• eat well;
• Do not self-medicate.

Minor emphysema resolves in two or three days, while more significant air accumulation may take up to ten days to resolve.

In general, subcutaneous emphysema, even of large sizes, rarely becomes dangerous for the patient. The cause of this condition itself is dangerous, and it is on its elimination that one should concentrate.

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