In patients with extensive subcutaneous emphysema ... - Oxford Journals

BEST EVIDENCE TOPIC – THORACIC

Interactive CardioVascular and Thoracic Surgery 18 (2014) 825–829 doi:10.1093/icvts/ivt532 Advance Access publication 26 February 2014

In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain? Charles H.N. Johnsona, Sommer A. Langb, Haris Bilalc and Kandadai S. Rammohanc,* a b c

School of Medicine, University of Sheffield, Sheffield, UK School of Medicine, University of Manchester, Manchester, UK Department of Cardiothoracic Surgery, University Hospital of South Manchester, Manchester, UK

* Corresponding author: Department of Cardiothoracic Surgery, South Manchester University Hospital, Manchester M23 9LT, UK. Tel:+44-791-7062966; fax: +44-161-2912685; e-mail: [email protected] (K.S. Rammohan). Received 24 June 2013; received in revised form 12 November 2013; accepted 25 November 2013

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: ‘In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain?’. Altogether more than 200 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Subcutaneous emphysema is usually a benign, self-limiting condition only requiring conservative management. Interventions are useful in the context of severe patient discomfort, respiratory distress or persistent air leak. In the absence of any comparative study, it is not possible to choose definitively between infraclavicular incisions, drain insertion and increasing suction on an in situ drain as the best method for managing severe subcutaneous emphysema. All the three techniques described have been shown to provide effective relief. Increasing suction on a chest tube already in situ provided rapid relief in patients developing SE following pulmonary resection. A retrospective study showed resolution in 66%, increasing to 98% in those who underwent video-assisted thoracic surgery with identification and closure of the leak. Insertion of a drain into the subcutaneous tissue also provided rapid sustained relief. Several studies aided drainage by using regular compressive massage. Infraclavicular incisions were also shown to provide rapid relief, but were noted to be more invasive and carried the potential for cosmetic defect. No major complications were illustrated. Keywords: Surgical emphysema • Subcutaneous emphysema • Drains • Suction • Air leak • Lung resection

INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

you resolve to check the literature for the best management strategy.

SEARCH STRATEGY

THREE-PART QUESTION

Combined results of two searches using Medline 1950 to August 2012 using Ovid interface:

In patients with extensive subcutaneous emphysema (SE), which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain?

(i) [SE OR surgical emphysema] AND [drain insertion OR drainage OR cutting OR incision OR blow holes OR suction]; (ii) [SE OR surgical emphysema] AND [management].

CLINICAL SCENARIO

SEARCH OUTCOME

You review a patient who has developed SE following a pulmonary resection. Over the next 24 h, the swelling expands to involve all of the torso, neck, face, arms and legs to the level of the knees. The patient complains of extreme discomfort and anxiety. He is no longer able to open his eyes and is having difficulty swallowing. Concerned about airway compromise,

Two hundred and seventy-four papers were found using the reported search. Papers that did not address management of SE or were concerned only with conservative management of SE were excluded. From these, 14 papers were identified that provided the best evidence to answer the question. These are presented in Table 1.

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

BEST EVIDENCE TOPIC

Abstract

C.H.N. Johnson et al. / Interactive CardioVascular and Thoracic Surgery

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Table 1: Best evidence papers Author, date, journal and country Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Cerfolio et al. (2008), Ann Thorac Surg, USA [2]

255 out of 4023 patients who underwent pulmonary resection developed clinically apparent SE

Developed recalcitrant SE

85 of 255 (33%)

Placement of additional chest tube at bed side

21 of 84

Patient with bedside insertion of chest tube were noted to have more time with recalcitrant SE than those who receive immediate VATS with air leak closure

Intervention: suction via chest tube

Single incision VATS placement

64 of 85

Relief from symptoms within 24 h of VATS chest tube insertion

63 of 64

Hospital stay (days)

VATS vs bedside chest tube 6 vs 9 (P = 0.02)

Sent home with chest tube attached to portable device

85 of 85

Time to resolution

1h

Retrospective cohort study (level III)

Lloyd and Jankowski (2009), Plast Reconstr Surg, UK [3] Case report (level V) Beck et al. (2002), Chest, Canada [4] Case report (level V)

2 patients developing life-threatening SE secondary to blunt traumatic pneumathoraces Intervention: liposuction via 28-FG chest drain 50-year old male with COPD exacerbation developed SE alongside recurrent pneumothoraces

Extra holes were put into 28-FG chest drain Mild bruising without haematoma formation was noted along the liposuction track

Time to resolution

3 days

Time to drain removal

5 days

Time to discharge

4 days after drain removal

Intervention: drainage via bilateral fenestrated 14-gauge angiocatheters

First description of this technique in the literature A 14-gauge cannula was modified to make a drain. Fenestrations were cut in a spiral pattern along its length Noted subcutaneous punctures used prior to drain insertion provided temporary relief until wound closed Catheter secured with 30 silk suture, but noted that further patients would have catheter secured with gauze to allow free air to escape No complications reported

Kelly et al. (1995), Anaesthesia, UK [5] Case report (level V)

Leo et al. (2002), Chest, Italy [6] Retrospective cohort study (level III)

77-year old male developed SE with bilateral pneumothorax post-pacemaker insertion


24 h

Time to discharge

1 week

28-FG chest drain modified by cutting extra holes along its length No complications were recorded

Intervention: drainage via modified 28-FG chest drain inserted subcutaneously 11 of 1008 patients following major thoracic surgery and 1 of 288 following mediastinoscopy developed SE requiring intervention Intervention: microdrainage via fenestrated angiocatheter

Time to resolution

1–3 days (n = 11)

Cannulas, modified as by Beck et al. were used

5 days (n = 1) Compressive massage three to four times daily needed to aid drain Study noted risk of occlusion to drain after 3 days SE recurred on removal of chest drain in 1 case. This required a further 2 days microdrainage

Continued


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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Open wound after drain removal allowed further air to be released for 12–24 h Srinivas et al. (2007), Med J, Singapore [7] Case report (level V)

50-year old male developed SE after pigtail drainage of pyogenic lung abscess


24 h

Time to resolution

12 h

Cannulas, modified as by Beck et al. were used Active compressive massage with patient face down and arms up used to increase hydrostatic pressure with the aim of aiding drainage—symptoms noted to improve only once massage was initiated

Intervention: drainage via fenestrated 14-gauge angiocatheter

No complications were noted

Case report (level V)

Cesaria et al. (2002), Chest, Italy [9] Retrospective cohort study (level III)

70-year old female developed extensive SE secondary to pleural puncture by subclavian catheter

Relief of symptoms

12 h


2 days after symptomatic relief

Cannulas, modified as by Beck et al. were used No complications were recorded

Intervention: drainage via bilateral fenestrated 14-gauge angiocatheter 19 patients developing SE post-thoracotomy for parenchymal lung resection and 1 patient post-VATS

Average duration of treatment

3.7 days (range 2–6 days)

A 5 mm, supraclavicular incision was made and the subcutaneous layers were separated by blunt instrument

20 patients developed SE post-lung parenchymal resection

Penrose-type drains—soft thin rubber tubes—were inserted into the space

Thoracotomy (n = 19), VATS (n = 1)

Repeated compression massage (three times per day) used to aid drainage

Intervention: drainage via Penrose drain

Noted to have incomplete records of 3 patients No complications were recorded

Matsushita et al. (2006), Heart Lung Circ, Australia [10] Case report (level V)

70-year old male developed SE postaortic valve replacement

Resolution of SE

Complete

Intervention: drainage via bilateral Penrose drains, covered by colostomy bag

Technique used was the same as in Cesaria et al. Colostomy bags over the insertion site kept wound sterile as well as providing measurements of the amount of air drained Patient required intubation during drainage No complications were noted

Sherif and Ott (1999), Tex Heart Inst J, USA [11]

70-year old male developed massive, expanding SE 12 h post-cardiac surgery

Case report (level V)

Intervention: drainage via Jackson-Pratt drain

Time to decompression of head and neck

3h

Time to extubation

48 h


7 days

Jackson-Pratt drains—a semi-rigid hollow tube with a bulb reservoir to provide suction—were inserted subcutaneously This case shows rapid resolution of symptoms without complication

Continued

BEST EVIDENCE TOPIC

Ozdogan et al. (2003), Intensive Care Med, Turkey [8]

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Table 1: (Continued) Author, date, journal and country Study type (level of evidence)

Patient group

Outcomes

Key results

Comments

Herlam et al. (1992), Chest, USA [12]

4 patients treated for extensive SE

Time to resolution