Subcutaneous emphysema of the chest, neck, face, lungs

If air bubbles accumulate in the subcutaneous fat tissue, then one speaks of a pathology such as subcutaneous emphysema. Usually, emphysema appears on the background of other diseases - for example, in the defeat of the respiratory system or esophagus.

[1], [2], [3]

Epidemiology

The word "emphysema" literally means "bloating" was first used by Hippocrates, describing the natural accumulation of gaseous bubbles in tissues.

Subcutaneous emphysema was described by the Dutch doctor Herman Burkhave in the 18th century. The symptom was related to the spontaneous rupture of the esophagus, as a result of which bubbles formed under the skin.

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

Accurate statistics of the disease are not maintained. There is evidence that, during laparoscopic access, subcutaneous emphysema, as a complication, occurs in 0.4-2.3% of cases.

It is also possible to develop subcutaneous emphysema as a result of dental procedures with the use of tools that work under increased pressure.

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

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

[4], [5], [6], [7], [8]

Causes of the subcutaneous emphysema

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

• spontaneous pneumothorax with damage to the parietal pleura;
• rupture of the lung with a fracture of the rib;
• penetrating wound of the breast;
• a 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, damage to the mucous tissues of the nose.

Subcutaneous fat can be filled with air when injuring the chest, respiratory organs, esophagus.

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

In some cases, subcutaneous emphysema appears after laparoscopy. To understand why this happens, it is necessary to delve deeper into the details of such an operation. Before the introduction of the laparoscope, the abdominal cavity of the patient is filled with carbon dioxide - to facilitate the advancement of instruments and the isolation of organs. The most frequent place of appearance of subcutaneous emphysema in this case is a puncture through which gas is injected: it can get into adipose tissue that lies directly under the skin. This is nothing terrible: this emphysema disappears on its own for a couple of days.

Subcutaneous emphysema after tooth extraction is considered a rare complication, however, its development can not be ruled out. Promotes the emergence of emphysema using instruments with air pressure on the gingival margin, especially when there is a dentogingival pocket, or with a loose fit of the gum. If the patient has a gum to the tooth fully, 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 passes by itself. But many dentists prescribe antibiotics as prevention.

[9]

Risk factors

The following factors can speed up the development of emphysema:

• congenital anomalies of the respiratory system;
• violation of the shape of the chest after injury;
• closed fracture of the rib with pulmonary penetration;
• chronic pulmonary intoxications;
• any penetrating wounds of the chest;
• pyogenic infections;
• bruises and closed chest injuries;
• swelling of the chest and neck;
• dental procedures using high-pressure apparatus;
• chronic long-term smoking, chronic bronchitis;
• barotrauma of the lungs;
• injuries of the joints;
• IVL, the use of the endotracheal tube.

[10], [11], [12], [13], [14], [15]

Pathogenesis

Subcutaneous emphysema is caused by a defect in the parietal pleura, when air enters the tissues with spontaneous pneumothorax.

Pneumothorax is the result of a pulmonary injury that occurred with the rupture of the pleura and the ingress of air into the near-air space.

In the pleural rupture, the lung falls and the respiratory capacity is impaired. The volume of air during each inhalation increases, which leads to an increased pressure in the cavity of the pleura.

The damaged outer pleural membrane passes through the air, which gets deep into the tissue and accumulates in the subcutaneous tissue, after which it disperses along the paths of minimal resistance.

Another variant of the development of emphysema: air penetrates into the tissues from the outside - for example, with injury or an open fracture of the chest. In such a situation, the development of pneumothorax does not occur, and emphysema itself is strictly localized.

Pneumothorax can be absent even when the cavity of the pleura is clogged with damaging fractures of the rib. In such patients, subcutaneous emphysema is formed when air enters from the mediastinum through the upper opening of the bone-cartilaginous skeleton through which the esophagus with the trachea lies.

[16], [17]

Symptoms of the subcutaneous emphysema

Subcutaneous emphysema appears in the joint or thoracic region. Subsequently, air can be displaced and spread throughout the body. As a rule, the direction of such spreading is upward to the head or down to the inguinal zone.

The first signs of the development of subcutaneous emphysema - this is a visible detectable tumor, with pressure on which you hear a typical crunch, called crepitus.

Directly emphysema does not directly threaten human life. However, theoretically, the tumor can exert a slight pressure on closely located vessels, which affects the patient's condition. In severe cases, other symptoms also join:

• violation of cardiac activity;
• pain behind the sternum;
• arrhythmia;
• instability of blood pressure.

If subcutaneous emphysema was a consequence of pneumothorax, then as an additional sign may be a violation of breathing, dyspnea, wheezing.

If emphysema occurs as a result of a trauma or a chest injury, then there will be trauma-related symptoms.

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

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

With prolonged emphysema, hepatic 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 trunk, including on the extremities, in the abdomen, etc. Directly, the patient does not suffer a pain tumor. Painful symptoms can be associated only with the initial cause of subcutaneous emphysema.

Stages

The spread of subcutaneous emphysema is carried out 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 the accumulation of air can be detected not only directly in the affected area, but also above it, and below it.
3. The total stage, which is characterized by a massive spread of air. This condition is considered threatening and occurs in such complex pathologies as damage to the lobar bronchi or valvular pneumothorax.

[18], [19], [20], [21]

Forms

If we base on the origin of subcutaneous emphysema, we can distinguish such types of this pathology:

• posttraumatic - is formed as a result of open or closed traumatic injury of the chest;
• iatrogenic - is formed as a complication after individual medical manipulations (for example, it is considered possible after endoscopy and some dental procedures).

The most likely sites of localization 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 an airway or esophagus injury, broken ribs, and also as a result of endoscopic interventions. Air from the subcutaneous space of the chest can go to the head and neck area, or lower - into the inguinal and femoral areas.
• Subcutaneous neck emphysema often occurs during complex procedures to remove the tooth, or after applying high-speed tips and syringes, pressurized air for manipulation in the oral cavity. In these cases, certain volumes of air fall under the skin through the groove of the gum.
• Subcutaneous emphysema of the face is characteristic for fractures of the bones of the facial skull, 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. More rarely a similar phenomenon is observed when the mucous tissues of the nasal cavity are damaged.

The subcutaneous accumulation of air on the face can spread to the region of the mediastinum.

[22], [23], [24], [25]

Complications and consequences

Usually, if you eliminate the cause of subcutaneous emphysema, it disappears on its own for several days.

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

• an increase in blood pressure in a small circle of circulation, pulmonary heart;
• increased intrapulmonary pressure, heart failure;
• hypoxemia (lowering the level of oxygen in the blood), hypoxia (lowering the level of oxygen in the tissues);
• paraseptal type of emphysema, which proceeds with destruction of alveolar membranes;
• pneumosclerosis;
• hemorrhages in the lungs;
• joining of a secondary infectious disease.

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

[26], [27], [28], [29]

Diagnostics of the subcutaneous emphysema

The diagnosis is made taking into account such moments:

• information about the history (taking into account the details of the period preceding the emergence of emphysema);
• examination with a palpation of the site of air localization under the skin (for subcutaneous emphysema, there is no pain, asymmetry and the presence of a crunch);
• results of additional studies.
• Analyzes in the laboratory include a general blood test. For emphysema such changes are characteristic:
• increase in the level of erythrocytes;
• increased hemoglobin levels;
• increase in hematocrit more than 47%;
• reduction of ESR;
• blood thickening.

Instrumental diagnostics consist of such procedures:

1. X-ray examination is carried out in the usual projection using an overview image.
2. Magnetic resonance imaging of the lung is done to assess the condition of large bronchi, lymphoid tissue and lungs.
3. Computer tomography is performed to obtain a detailed layered image of the structure of the lungs.
4. Lung scintigraphy involves the introduction into the respiratory system of labeled radioactive isotopes and imaging with a gamma camera. Scintigraphy helps to detect vascular disorders, induced by emphysema.

[30], [31], [32], [33], [34], [35]

Differential diagnosis

Differential diagnosis is mandatory, as there are other pathologies that can cause an increase in volume. To such pathologies, first of all, hematomas (blood accumulation in tissues), allergic reactions and Quincke's edema should be referred .

[36], [37], [38], [39], [40], [41], [42]

Treatment of the subcutaneous emphysema

Since subcutaneous emphysema resolves itself without any medical intervention, the treatment is directed only at eliminating the causes of its appearance.

If emphysema was triggered by pneumothorax, the doctor punctures the air from the pleural cavity with a puncture. If this procedure is unsuccessful, it means that air continues to come from the lung tissue: it is necessary to create a sealed drainage cavity of the pleura, or install an active suction system - for example, using an electrovacuum device.

In the case where the application of the above methods did not bring the expected results, surgical treatment is performed. For example, if a chest is injured, thoracotomy and suturing damage are performed.

To improve the general condition of the patient, prescribe medications:

Anesthetics
Ketolong, Analgin, Sedalgin	Take one tablet twice a day, with chest pains
Glucocorticosteroid preparations
Prednisolone, Dexamethasone	For the prevention and treatment of inflammation take 1 tablet twice a day
Vitamins
Undevit, Revit, Decamewith	Take one tablet or tablet 2-3 times a day, to strengthen the immune defense
Antibiotics
Ceftriaxone, Ofloxacin, Amoxyl	Assign with the appearance of an infectious complication, or with the growth of signs of inflammation
Means against cough
Libexin, Ambroxol, Flavamed	Take one tablet up to three times a day, to facilitate coughing and expectoration

When prescribing a particular drug, the probability of side effects is necessarily taken into account. Before starting treatment, you should carefully read the instructions for each of the prescribed medications.

Physiotherapeutic treatment

To prevent the negative effects of subcutaneous emphysema, it is recommended to do respiratory gymnastics, 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. Such an exercise should be practiced every day, 4 times a day.

Respiratory gymnastics will help restore the function of bronchi and alveoli, which provide a gas exchange process.

The physical load for patients with subcutaneous emphysema should be temporarily limited.

It is recommended to systematically massage the area of the chest, avoiding the area of air accumulation, which can not be massaged. Therapeutic massage of the breast will help to avoid stagnation in the lungs.

Alternative treatment

• It is desirable every day, morning, afternoon and evening to drink 50 ml fresh potato juice, this will have a positive effect on oxygen metabolism in tissues.
• For several months you need to regularly use honey - on a tablespoon up to three times a day. This will strengthen immunity and prevent the development of the inflammatory process.
• You should include walnuts in the menu: to improve your well-being, it is enough to eat 1 2 walnuts daily.
• When brewing tea it is useful to add melissa or dried leaves of plantain to it.
• It is useful to conduct warm coniferous inhalations daily.

Herbal Treatment

Treatment of subcutaneous emphysema due to damage to the respiratory or digestive organs is a rather complex and diverse process, the main purpose of which is the restoration of the function of damaged systems.

As an adjunct to the main treatment, it is possible to coordinate with the doctor the use of such alternative recipes on herbs:

• Prepare an infusion of equal parts of juniper fruit, birch leaves and dandelion roots. Take 200 ml twice a day for half an hour before meals.
• Prepare tea from the same parts of birch leaves and horsetail grass. Drink 150 ml throughout the day three times, before eating.
• Prepare the infusion of such plants: fennel seeds 10 g, elderberry color 10 g, cumin seeds 10 g, goricvet 10 g, parsley seeds 30 g, juniper berries 30 g. One glass of infusion is drunk three times during the day.
• Prepare tea on the basis of 50 g of birch leaves, 20 g of hips and 20 g of rhizome. Drink a third of the glass, up to four times a day, half an hour before a meal.

Homeopathy

Treatment of complicated cases of subcutaneous emphysema can be supplemented by the application of homeopathy:

• Lobelia 3x, 3 - with shortness of breath, which accompanies emphysema;
• Tartarus emeticus 3, 6 - with bubbling and wheezing, with disturbed tone of the lungs;
• Ipecacuano 3 - with convulsions of the chest;
• Antimonium arsenikozum 3, 6 with heart failure and bronchitis;
• Carbo vegetabilis 3x, 3, 6 - with strong atrophic changes in the lungs;
• Curare 3, 6 - with severe respiratory failure.

Homeopathic medicines are prescribed by a special homeopath physician, who selects them individually.

Such remedies are distinguished by the absence of contraindications and side effects - only occasionally drugs can lead to the appearance of allergies.

Prevention

The necessary preventive measures for the prevention of subcutaneous emphysema are:

• Timely call to the doctor for any pathology of the respiratory system.
• Conduct a regular full course of treatment of chronic respiratory diseases.
• Providing protection for chronic and acute intoxications of the respiratory tract.
• Strengthening the defenses of the body, hardening, active way of life.
• Getting rid of smoking.
• Prevention of chest injuries.
• Periodical trips to the sea, to the forest: Fresh clean air (especially sea or coniferous) helps to cleanse the airways and improve the body as a whole.

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

[43], [44], [45], [46], [47], [48], [49], [50], [51]

Forecast

The prognosis is considered favorable provided that the root cause of subcutaneous emphysema is eliminated. To speed up the recovery process, one should adhere to such recommendations:

• to quit smoking forever;
• prevent the development of infectious diseases;
• more likely to be out in the fresh air;
• fully nourished;
• not engage in self-medication.

A small emphysema passes for two or three days, and a more significant accumulation of air can be eliminated up to ten days.

In general, subcutaneous emphysema of even large sizes rarely becomes dangerous for the patient. The very cause of this condition is dangerous, the elimination of which should be concentrated.

[52], [53], [54], [55]