[size=6]A 4-year-old was admitted to the PICU in ARDS. Ventilator settings include 100% FiO2, PRVC with TV of 5.5 ml/kg, RR 28, PEEP 12mmHg. Arterial blood gas showed: pH 7.42, pCO2 53, pO2 75, HCO3 34, base excess 8. You were called to help manage this finding on her CXR. It was interpreted as “significant pneumomediastinum, no pneumothorax, and significant subcutaneous emphysema."

On examination, patient has crepitus to the forehead and upper extremities to the wrist, back to iliac crests.

Examination did not show any pharyngeal injury. Esophagoscopy and bronchoscopy demonstrated mucosal integrity. The next best step is

 

 

a jet ventilation or high frequency oscillatory ventilation

 

b multiple incisions in areas of crepitus

 

c mediastinal tube placement

 

d bilateral chest tubes

 

e bilateral infraclavicular incisions[/size]

A

(a) jet ventilation or high frequency oscillatory ventilation

 

Air leak syndrome from barotrauma

B

correct answer

e bilateral infraclavicular incisions

 

Treatment for severe subcutaneous emphysema requires urgently addressing the underlying air leak, such as usually via chest tube placement for pneumothoraces while simultaneously decompressing the subcutaneous tissue to prevent airway compromise. For symptomatic or refractory SE, the most effective decompression techniques move beyond conservative management to active venting. These techniques include creating controlled "blowhole" incisions in the infraclavicular area to vent air passively, the use of large-bore angiocatheters for rapid, temporary relief, or the application of Negative Pressure Wound Therapy (NPWT/VAC) over the incisions for aggressive, sustained air evacuation. The choice of technique is tailored to the severity, though comparative reviews confirm that all methods provide effective, temporary relief while the definitive source of the leak is controlled. Multiple subcutaneous incisions are usually not required.

 

While HFOV or jet ventilation can help with a leak, this patient’s oxygenation and ventilation are currently not compromised. Chest tubes are not necessary when there are no pneumothoraces. Mediastinal tube placement is difficult. Chest Xray below shows the patient 3 days after drain placement.