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1127: LUNG ULTRASOUND THE FINE LINE BETWEEN DIAGNOSING AND RULING OUT PNEUMOTHORAX

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Subcutaneous emphysema is usually selflimiting, and patients have a benign clinical course. However, we describe a rare complication of subcutaneous emphysema following removal of chest tube. Methods: A 80 year old woman with past medical history of COPD presented with worsening dyspnea and a non-productive cough. In the Emergency Department, she was found to have a large left pneumothorax, and a tube thorocostomy was performed. Resolution of the pneumothorax resulted in subsequent removal of the chest tube. One hour after chest tube removal, patient began to have progressive facial swelling and erythema accompanied by dysphagia, difficulty breathing, and a sensation of suffocation. Patient was sitting bolt upright and answered questions with a low voice and intermittent oxygen desaturation to 86% on room air. There was palpable crepitus over the chest, neck, and face. Auscultation of the lungs revealed scattered rhonchi and decreased breath sounds on the left. A chest x-ray showed extensive chest wall and neck subcutaneous emphysema as well as pneumomediastinum. A CT of the chest revealed a moderate left pneumothorax and new pneumomediastinum. CT of the neck showed extensive subcutaneous emphysema throughout the soft tissues of the neck with dissection into the paraapharyngeal space, carotid space, retropharyngeal, and perisubmandibular space. Given the concern for rapid upper airway compromise, the patient was intubated and given low tidal volumes and a left side chest tube was re-inserted. Results: This case illustrates an interesting critical care case dilemma. Intubation with positive pressure in the patient would most likely worsen the patient’s underlying disease; however, there was also concern for upper airway compromise at the time of evaluation. Several cases of fatal incidents of subcutaneous emphysema have been reported. Intensivists should carefully weigh the risk of positive pressure in patients with seemingly benign subcutaneous emphysema and in respiratory distress versus the potential risk of death from asphyxiation.