Subq emphysema

[dabears505]

Do you have any rules to follow on deciding if not to pull et tube after a case which a ton of sub q emphysema has occurred?

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[Arch Guillotti]

Do you have any rules to follow on deciding if not to pull et tube after a case which a ton of sub q emphysema has occurred?

Michelin Man test. Proceed with caution if positive.

 

[coffeebythelake]

Do you have any rules to follow on deciding if not to pull et tube after a case which a ton of sub q emphysema has occurred?

You mean like after laparoscopic surgery and co2 insufflation? I would consider the patients cardiopulmonary status and how likely the patient will be able to breathe off that extra co2

 

[nimbus]

SBT in OR to make sure they maintain a reasonable ETCO2 and O2 sat, check for airleak around ETT if there’s a concern about airway.

 

[anbuitachi]

Do you have any rules to follow on deciding if not to pull et tube after a case which a ton of sub q emphysema has occurred?

agree with above. proceed with caution. look for hemodynamic issues. there may be emphysema in the airways. can do leak test if it makes you feel better

 

[GassYous]

Also would do a leak test. If their etco2 is reasonable and they can ventilate they can have the tube out. If there's any question I have no problem leaving the tube in and letting them rest overnight.

 

[Guillemot]

Aren't leak tests supposed to be of poor prognostic value? Im not saying I wouldnt do one and use it as part of my approach, but I’d also be inclined to examine the airway with video laryngoscopy and bronchoscopy before committing to a decision. If it didn't look swollen, and the airway did not otherwise appear difficult, then Id consider extubation even without a leak. Actually, this is what I’d do in a high resource environment. Out in PP the patient stays tubed if I have any concern.

 

[Beeftenderloin]

Leak tests are reassuring, but are by no means a fail safe. Have been burned before with positive leak test and extubation with subsequent worsening of edema requiring reintubation.

 

[cchoukal]

It depends on the nature of the empysema. Post-laparoscopy insufflation? NBD. Any chance this is 2/2 pneumothorax or pneumoediastinum? If the case carried the risk (e.g., esophagectomy, prolonged liver dissection, etc.) I'd ultrasound the chest to r/o a PTX, and if the hemodynamics were okay, I'd be less worried about pneumomediastinum. If the neck weren't too swollen/affected, I'd extubate.

 

[Gern Blansten]

I have a colleague who uses extubation over a Cook catheter to see how they do for 30 minutes or so. Patients that I have seen him use this on have tolerated it fairly well. If they fail, you have a conduit for reintubation already in place. If that fails, there is a lumen (very small) on the catheter that you could deliver oxygen through.

 

[PainDrain]

I have had four cases of massive subQ emphysema (one from an outpatient scope with esophageal perf, others from laparoscopy). The one from the esophageal perforation had voice changes following the perforation and prior to the repair, I extubated her based on the fact she was a very easy intubation. One of the laparoscopic cases ended up staying tubed because her end tidal was 80 and on a blood gas was somewhere around 7.1 if I recall. I changed her vent setting and got serial ABGs then extubated in pacu after about 4 hours. The others were due to air tracking during hiatal hernia repairs and their end tidal CO2s were never that high so I felt comfortable extubating. I don’t have any hard and fast rules about anything and do everything on a case by case basis.

 

[IlDestriero]

I was called to intubate a little kid who had massive SQ emphysema, pneumothoraces and pneumomediastinum. It was memorable.
The phrase better lucky than good came to mind after I found a dark area with a glide, put a tube in it, and confirmed ETCO2. I was fairly certain they were going to get a terrible slash trach and fishing expedition by the ENT resident at the bedside with the parents watching the massacre. Mini me Michelin Man, couldn’t mask vent at all, LMA barely kept the O2 in the 80’s.

 

[nimbus]

I was called to intubate a little kid who had massive SQ emphysema, pneumothoraces and pneumomediastinum. It was memorable.
The phrase better lucky than good came to mind after I found a dark area with a glide, put a tube in it, and confirmed ETCO2. I was fairly certain she was going to get a terrible slash trach and fishing expedition by the ENT resident at the bedside with the parents watching the massacre. Mini me Michelin Man, couldn’t mask vent at all, LMA barely kept the O2 in the 80’s.

Wow. What was the back story? Was it iatrogenic/postop? Trauma?

 

[nimbus]

Atypical subQ air

 

[IlDestriero]

Wow. What was the back story? Was it iatrogenic/postop? Trauma?

Syndromic kid with a palatoplasty went back on BiPap post op. Transferred to PICU. BiPap escalated as respiratory status got worse over several hours and then it got exciting when they had a respiratory arrest around 2 am. My favorite time for an airway emergency call.

 

[Ronin786]

It depends on the nature of the empysema. Post-laparoscopy insufflation? NBD. Any chance this is 2/2 pneumothorax or pneumoediastinum? If the case carried the risk (e.g., esophagectomy, prolonged liver dissection, etc.) I'd ultrasound the chest to r/o a PTX, and if the hemodynamics were okay, I'd be less worried about pneumomediastinum. If the neck weren't too swollen/affected, I'd extubate.

Ultrasound is going to be a very poor way to rule out PTX in a patient with subcutaneous emphysema since the whole premise behind ultrasonographic imaging of PTX is that air between the probe and pleura prevents visualization of lung sliding.

 

[nimbus]

Ultrasound is going to be a very poor way to rule out PTX in a patient with subcutaneous emphysema since the whole premise behind ultrasonographic imaging of PTX is that air between the probe and pleura prevents visualization of lung sliding.

Good point. It’s been pretty worthless the few times I’ve put a probe on a patient with subQ emphysema.