Case of tracheal rupture after endotracheal intubation: clinical risk management and medico-legal considerations.

Background: Tracheal injury may be a rare complication of the endotracheal intubation procedure. Incidence and determinant factors are not well known, nevertheless a greater incidence have been recognized with a difficult maneuver or the use of nitrogen peroxide. The therapeutic approach can be conservative or surgical, depending on the characteristics of the lesion and of the patient and therefore the outcomes of medico-legal interest can be different. Case description: It is a case of alleged medical liability regarding a 70-year-old woman, that during the intubation procedure was pouncing on the right. Furthermore, nitrous oxide was used as an anaesthetic. A few hours after the operation the patient showed swelling on the right half of the face and on the right lateral region of the neck. The emergency chest CT scan highlighted subcutaneous emphysema and pneumomediastinum. In the operating room, fibrobronchoscopy was performed with a double-lumen bronchial tube which confirmed the hypotheses lesion; then, right posterolateral thoracotomy was perfor-med followed by suturing of the tracheal lesion. Subsequently, the patient was discharged in good clinical conditions but with a scar in the region of the right hemithorax. Conclusions: Iatrogenic tracheal injury is a rare and fearful complication of the orotracheal intubation procedure. Although risk factors that increase the probability of its onset have been recognized, in most cases it is not possible to identify the cause. From a medico-legal point of view, tracheal injury after intubation is unpredictable and inevitable, so in the case reported it was decided to proceed with a conciliatory solution.

Spontaneous pneumomediastinum and surgical emphysema presenting as rhinolalia following ecstasy ingestion: a case report.

BACKGROUND: We present a unique case of rhinolalia as the first recognizable sign of spontaneous pneumomediastinum and surgical emphysema following drug use. CASE PRESENTATION: This case presents a 17-year-old white male experiencing rhinolalia following ecstasy ingestion at a rave. Subsequent chest X-ray revealed extensive surgical emphysema, along with a continuous diaphragm sign indicative of pneumomediastinum. Computed tomography confirmed the diagnosis. The patient was managed conservatively with strict monitoring and 6 hourly electrocardiograms. Follow-up computed tomography on day 3 showed resolution of pneumomediastinum and surgical emphysema, and the patient was safely discharged. Notably, the patient experienced a temporary rhinolalia during the acute phase, which resolved spontaneously as his condition improved. CONCLUSIONS: This case underscores the importance of considering spontaneous pneumomediastinum and surgical emphysema in the differential diagnosis of young individuals presenting with acute symptoms after drug use.

Comparison of AirSeal versus conventional insufflation system for robot-assisted partial nephrectomy: a meta-analysis and systematic review.

A systematic review and meta-analysis were performed to investigate the efficacy of the AirSeal Valveless Trocar Needle Insufflation System in robot-assisted partial nephrectomy (RAPN). The study compared the differences in perioperative outcomes between the AirSeal insufflation group (AIS) and the conventional insufflation group (CIS). A systematic search of databases such as PubMed, Embase, Cochrane library, and Web of science was performed to identify studies reporting perioperative outcomes between the AirSeal insufflation group (AIS) and the conventional insufflation group (CIS) in RAPN. The study protocol is registered with PROSPERO (CRD42024524335). The primary outcome was to compare the incidence of subcutaneous emphysema (SCE) and postoperative pain scores between the two approaches. The review included four studies with 379 patients, 194 in the AIS group and 185 in the CIS group. Baseline characteristics of the two groups were similar in all outcomes. SCE was significantly lower in the AIS group than in the CIS group [(OR) 0.30 (0.16, 0.54), p < 0.001]. Postoperative 12-h pain scores were also significantly lower in the AIS group compared to the CIS group [(WMD) - 0.93 (- 1.67, - 1.09), p = 0.014]. Both groups showed a significant reduction in length of hospitalization [(WMD) - 0.12 (- 0.84, 0.60), p = 0.746], thermal ischemia time [(WMD) 4.72 (- 5.71, 15.15), p = 0.375], amount of lost hemoglobin [(WMD) - 0.19 (- 0.53, 0.15), p = 0.284], pneumothorax [(OR) 0.13 (0.02,1.10), p = 0.062], mediastinal emphysema [(OR) 0.55 (0.20, 1.46), p = 0.230], and 4-h pain score [(WMD) - 0.25 (- 1.16, 0.65), p = 0.584]; no significant differences were observed. The incidence of subcutaneous emphysema SCE and 12-h pain scores were significantly lower in the AIS group compared to the CIS group. The AirSeal system demonstrated similar efficacy and a higher safety profile than the conventional insufflation system in robotic-assisted partial nephrectomy; however, due to the lack of a randomized study on the topic, further data are needed.

Cervicofacial Subcutaneous Emphysema and Pneumomediastinum Following Class V Resin Restoration: A Case Report.

Air can become trapped within the subcutaneous layer of the cervicofacial area, a condition known as subcutaneous emphysema (SE), unexpectedly after routine dental procedures. SE can worsen by extending superiorly to the peri-orbital region and inferiorly to the thorax and abdomen along the fascial planes. Upward progression can result in cavernous sinus thrombosis. Conversely, downward progression can cause a variety of complications such as pneumothorax, mediastinitis, and compression of the venous trunks. The presence of these conditions highlights the significance of prompt identification, precise diagnosis to ascertain the need for immediate intervention, and suitable management to prevent additional unfavorable consequences.

Air leak syndrome in animals: definition and pathogenesis.

Air leak syndrome (ALS) is described in human medicine as a constellation of clinical disorders including pneumomediastinum, pneumopericardium, pulmonary interstitial emphysema, pneumothorax, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema. The pathogenesis of ALS depends on the anatomy of the mediastinum and its associations with thoracic, abdominal and cervical connective tissues, as well as a physical phenomenon referred to as the Macklin effect. Various animal species develop diverse combinations of these lesions, although ALS has not been recognized in animals. However, this term aids pathologists in addressing this disease compilation. The aim of this retrospective study is to illustrate examples of ALS in animals by arbitrarily selecting 13 cases in dogs, cats, pinnipeds, sea otters and harbour porpoises. ALS can be classified into three groups based on aetiology: iatrogenic, secondary or spontaneous. Iatrogenic ALS was diagnosed in two cats with tracheal laceration following endotracheal intubation. Secondary ALS was identified in two dogs, one with acute respiratory distress syndrome and the other due to grass awn migration. Secondary ALS in pinnipeds was diagnosed following severe pulmonary parasitism, uraemic pneumonia and oesophageal perforation. The other marine mammals developed ALS following trauma. Spontaneous ALS was also diagnosed in one cat and one dog without any apparent predisposing causes.

Conservative Management of Large Post-Intubation Tracheal Laceration.

ABSTRACT: Tracheal rupture is a very rare but life-threatening complication of endotracheal intubation. It is more common in women and patients older than 50 years old. Overinflation of endotracheal tube cuff and tracheal wall weakening are the most important pathogenetic mechanisms. Laceration sites are located in the posterior membranous wall in most cases. Subcutaneous and mediastinal emphysema and respiratory distress are the most common manifestations. A 55-year-old female presented with postoperative subcutaneous and mediastinal emphysema without dyspnea because of a tear in the posterior tracheal wall. The diagnosis was based on clinical manifestation, chest computer tomography scans (CT), and endoscopic findings. A conservative approach by broad-spectrum antibiotic therapy was decided because of patients' vital signs stability and the absence of esophageal injury. The follow-up showed that there was no lesion in the posterior tracheal wall. Our case showed that in clinically stable patients without mediastinitis and with spontaneous breathing, conservative management of tracheal tears is a safe procedure.

Tracheal Schwannoma Presenting as Subcutaneous Emphysema and Pneumomediastinum.

Primary tracheal schwannomas are rare benign tumours. This is a case report, and therefore, no specific methods or results are applicable. We here report a case of a tracheal schwannoma in an early adolescent girl presenting with subcutaneous emphysema and symptoms of airway obstruction. Tracheal resection and reconstruction by primary anastomosis were performed. Pathology confirmed the diagnosis of tracheal schwannoma. This is an unusual life-threatening presentation of a benign rare tracheal tumour with a challenging approach to management.

Pneumothorax, pneumomediastinum and subcutaneous emphysema as respiratory complications of COVID-19.

BACKGROUND: Pneumothorax, pneumomediastinum and subcutaneous emphysema are respiratory complications of Coronavirus disease 2019 occurring with noteworthy frequency in patients especially with severe disease. They can be life-threatening and often complicate patient managment. METHODS: This was a retrospective, observational study of patients admitted in Nepal Armed Police Force hospital from 13/05/2020 to 28/12/2021 diagnosed with pneumothorax, pneumomediastinum or subcutaneous emphysema singly or in combination. Data were collected from clinical charts, imaging records and electronic medical records of Severe Acute Respiratory Syndrome Coronavirus-type 2 positive patients 18 years and older. The frequency and type of the defined complications, the inflammatory markers and ventilatory parameters just prior to their diagnosis, the duration of hospitalization and ICU admission and in-hospital mortality rate were studied. RESULTS: Out of 4013 COVID-19 patients admitted in the hospital during the period, a total of 28 patients were observed to develop the complications, the overall incidence being 0.7% among hospitalized patients and 5.6% among ICU patients. The proportion of subcutaneous emphysema (64.3%) was highest followed by pneumomediastinum (46.4%) and then pneumothorax (39.3%) existing singly or in combination among the 28 patients, where four patients developed the complications spontaneously. Mean Positive End Expiratory Pressure of 12.1±2.6 cmH2O and Peak Inspiratory Pressure or Pressure Support of 30.9±10.3 cmH2O were observed for patients under positive pressure ventilation. Most of the patients who developed the complications (78.6%) died during treatment. CONCLUSIONS: Pulmonary air leak complications occur frequently in COVID-19 patients treated with or without positive pressure ventilation signifying increased disease severity, risk of ICU admission and high mortality rate. Hence, clinicians should be vigilant of these complications in all patients affected with COVID-19 and institute timely management.

Trivial trauma to the cheek: significant complications in the chest.

A man in his 30s presented to the emergency department with a history of injury to the face with a crowbar. He was discharged from the department, in the absence of any facial bone fractures and given normal examination findings, except for a puncture wound on the mentum. The patient then re-presented within 24 hours with extensive cervical emphysema extending into the mediastinal cavity.He was referred to ear, nose and throat team for further management. CT scan of the chest and neck showed extensive surgical emphysema and a pneumomediastinum. The patient was managed conservatively and recovered well with no significant sequelae.Even in the absence of facial bone fractures, it is imperative to understand the force of impact which should prompt a consideration of imaging of the chest. Appropriate advice regarding avoidance of Valsalva manoeuvres will help prevent extensive propagation of air through the fascial planes that can result in a pneumomediastinum.

Neumomediastino espontáneo: una manifestación extramuscular de la dermatomiositis anti-MDA5. Reporte de 2 casos / Spontaneous pneumomediastinum: An extra muscular manifestation of anti-MDA5 dermatomyositis. Report of 2 cases

El uso de anticuerpos específicos en miopatías inflamatorias ha mejorado la caracterización de esta enfermedad identificando distintos fenotipos clínicos. Los pacientes con dermatomiositis y anticuerpos anti-MDA5 muestran síntomas típicos en la piel, un menor compromiso muscular y una prevalencia de enfermedad pulmonar intersticial de hasta el 91%. Además de la enfermedad pulmonar intersticial, se ha identificado el neumomediastino espontáneo como una manifestación pulmonar rara pero potencialmente mortal. Se reportan 2 casos de esta manifestación en pacientes con dermatomiositis anti-MDA5.(AU)

The use of specific antibodies in inflammatory myopathies has improved the characterization of this disease, identifying different clinical phenotypes. Patients with dermatomyositis and anti-MDA5 antibodies display typical skin symptoms, lesser muscular involvement, and a prevalence of interstitial lung disease of up to 91%. Beyond interstitial lung disease, spontaneous pneumomediastinum has been identified as a rare but potentially fatal pulmonary manifestation. Two cases of this complication in patients with anti-MDA5 dermatomyositis are reported.(AU)

Safety of cricotracheostomy with skin and tracheal membrane flaps for severe COVID-19 patients.

OBJECTIVE: Airway surgery is performed for COVID-19 patients who require long-term tracheal intubation and mechanical ventilation. Tracheostomy sometimes causes postoperative complications represented by bleeding at a relatively high rate in COVID-19 patients. As an alternative surgical procedure to tracheostomy, cricotracheostomy may reduce these complications, but few studies have examined its safety. METHODS: Data were retrospectively collected for sixteen COVID-19 patients (11 underwent tracheostomy, 5 underwent modified cricotracheostomy). In addition to patients' backgrounds and blood test data, the frequency of complications and additional care required for postoperative complications were collected. Statistical analysis was conducted by the univariate analysis of Fischer analysis and Mann-Whitney U test. RESULTS: Five cases experienced postoperative bleeding, four cases experienced peristomal infection, and one case experienced subcutaneous emphysema in the tracheostomy patients. These complications were not observed in the cricotracheostomy patients. The number of additional cares for postoperative complications was significantly lower in cricotracheostomy than in tracheostomy patients (p < 0.05). CONCLUSIONS: Modified cricotracheostomy could be a safe procedure in airway surgery for patients with COVID-19 from the point of fewer postoperative complications and additional care. It might be necessary to select the cricotracheostomy depending on patients' background to reduce postoperative complications.

Subcutaneous emphysema associated with laparoscopic or robotic abdominal surgery: a retrospective single-center study.

BACKGROUND: Subcutaneous emphysema (SCE) is a common complication in laparoscopic surgery. However, its precise incidence and impact on the clinical course are partially known. In this study, the incidence and risk factors of SCE were retrospectively analyzed. METHODS: Patients who underwent laparoscopic/robotic abdominal surgery (e.g., gastrointestinal, hepatobiliary, gynecologic, and urologic surgery) between October 2019 and September 2022 were retrospectively analyzed. The presence of SCE was confirmed by either conclusive findings obtained through chest/abdominal X-ray examination immediately after operation, or intraoperative palpation conducted by nurses. X-ray examination was performed in the operation room before extubation. RESULTS: A total of 2503 patients treated with laparoscopic/robotic abdominal surgery between October 2019 and September 2022 were identified and all of them were included in the analysis. SCE was confirmed in 23.1% of the patients (i.e., 577/2503). SCE was identified by X-ray examination in 97.6% of the patients. Extubation failure was observed in 10 patients; however, pneumothorax was not observed. Female sex (odds ratio [OR]: 2.09; 95% confidence interval [95%CI]: 1.69-2.57), age ≥ 80 years (OR 1.63; 95%CI 1.19-2.22), body mass index < 20 (OR 1.32; 95%CI 1.06-1.65), operation time > 360 min (OR 1.97; 95%CI 1.53-2.54), robotic surgery (OR 2.54; 95%CI 1.91-3.38), maximum intraabdominal pressure with CO2 > 15 mmHg (OR 1.79; 95%CI 1.02-3.16), and endo-tidal CO2 > 50 mmHg (OR 1.32; 95%CI 1.08-1.62)were identified as independent factors of SCE. Regarding the extubation failure due to SCE, age (OR 5.84; 95%CI 1.27-26.8) and maximum intraabdominal pressure with CO2 (OR 21.7; 95%CI 4.76-99.3) were identified as risk factors. CONCLUSION: Although the presence of SCE is associated with a low risk of severe complications, monitoring of the perioperative intraabdominal pressure is essential for performing safe laparoscopic/robotic surgery, particularly in elderly patients.

Traumatic subcutaneous emphysema following blood donation: A case report.

BACKGROUND: Subcutaneous emphysema is a condition where air becomes trapped under the skin, typically resulting from surgery or skin trauma. It is mostly localized and its occurrence in blood donors is exceedingly rare. Phlebotomy poses minimal risk of subcutaneous emphysema, but procedural errors may lead to such complications. STUDY DESIGN AND METHOD: This is a case report of 29-year-old repeat blood donor who experienced subcutaneous emphysema following blood donation. The donor was vigorously squeezing sponge ball during donation resulting in displacement of the needle which required readjustment. Post-donation, the donor reported a crackling sensation and mild swelling near phlebotomy site. Non-contrast computed tomography (NCCT) scans confirmed subcutaneous emphysema, attributing its development to air trapping in subcutaneous plane due to ball valve mechanism. RESULTS: Computed tomography (CT) imaging revealed subcutaneous emphysematous changes in the right cubital region and no evidence of hematoma. The swelling spontaneously subsided in 10-12 days without any intervention. The case underscores the importance of differentiating subcutaneous emphysema from common complications like hematoma. DISCUSSION: Subcutaneous emphysema in blood donors is exceptionally rare but should be managed with clear communication. Donors should be reassured that the condition, although rare, is benign and self-resolving. Healthcare providers should be equipped to handle such rare complications, offering appropriate care and documenting incidents for future prevention.

Macklin Effect: From Pathophysiology to Clinical Implication.

Air leak syndromes (such as pneumomediastinum, pneumothorax, or subcutaneous emphysema) are frequent complications of acute respiratory distress syndrome (ARDS). Unfortunately, the development of air leaks is associated with worse outcomes. In addition, it has been hypothesized that the development of pneumomediastinum could be a marker of disease severity in patients with respiratory failure receiving noninvasive respiratory support or assisted ventilation. The so-called Macklin effect (or pulmonary interstitial emphysema) is the air dissection of the lung bronchovascular tree from peripheral to central airways following injury to distal alveoli. Ultimately, the progression of the Macklin effect leads to the development of pneumomediastinum, subcutaneous emphysema, or pneumothorax. The Macklin effect is identifiable on a chest computed tomography (CT) scan. The Macklin effect could be an accurate predictor of barotrauma in patients with ARDS (sensitivity = 89.2% [95% CI: 74.6-96.9]; specificity = 95.6% [95% CI: 90.6-98.4]), and may be a marker of disease severity. Accordingly, the detection of the Macklin effect on a chest CT scan could be used to select which patients with ARDS might benefit from different treatment algorithms, including advanced respiratory monitoring, early intubation, or, potentially, the institution of early extracorporeal support with or without invasive ventilation. In this video, the authors summarize the pathophysiology and potential clinical significance and applications of the Macklin effect in patients with acute respiratory failure.

Risk factors and clinical significance of subcutaneous emphysema after robot-assisted laparoscopic rectal surgery: a single-center experience.

Subcutaneous emphysema (SE) is a complication of laparoscopic surgery, potentially resulting in severe respiratory failure. No reports to date have focused on SE during robot-assisted (RA) rectal surgery. We aimed to reveal the risk factors and clinical significance of SE after RA/laparoscopic rectal surgery. We retrospectively reviewed 221 consecutive patients who underwent RA/laparoscopic rectal surgery. The occurrence of SE was evaluated on postoperative radiographs. Laparoscopic surgery was performed in 120 patients and RA in 101. SE developed in 55 (24.9%) patients. Logistic regression analysis identified RA surgery (odds ratio [OR]: 4.89, 95% confidence interval [CI] 2.13-11.22, p < 0.001), higher age (OR: 1.06, 95% CI 1.03-1.11, p < 0.001), lower body mass index (BMI) (OR: 0.79, 95% CI 0.67-0.93, p = 0.004), thinner subcutaneous layer (OR: 0.88, 95% CI 0.79-0.98, p = 0.02), and lateral lymph node dissection (OR: 9.43, 95% CI 2.44-36.42, p < 0.001) as risk factors for SE. Maximum end-tidal CO2 was significantly higher in the SE than the non-SE cohort (p < 0.001). There was no difference in postoperative complication rate or length of hospital stay. Lower BMI (OR: 0.79, 95% CI 0.62-0.97, p = 0.02) and thinner subcutaneous layer (OR: 0.84, 95% CI 0.71-0.97, p = 0.01) were predictive factors in the RA cohort. SE occurs more frequently in RA compared with laparoscopic surgery. SE has a modest impact on short-term outcomes, but may occasionally cause severe problems. The indication of RA surgery should be considered carefully in high-risk elderly patients.

Iatrogenic gas embolism in a juvenile loggerhead sea turtle (Caretta caretta).

A mild pneumocoelom was diagnosed by computed tomography in a stranded juvenile loggerhead sea turtle (Caretta caretta). After gas extraction by ultrasound-guided puncture, the animal did not improve and was subjected to hyperbaric oxygen therapy (HBOT). After HBOT, the turtle developed marked subcutaneous emphysema and was found dead the following morning. Gross lesions included a distended right atrium with numerous gas bubbles within the epicardium, gas bubbles in the hepatic, gastric and mesenteric veins, a small gas-filled bulla in the left lung and diffuse haemorrhages in the encephalon. Histological lesions included gas-like emboli in the lumen of the right atrium with myocardial necrosis, gas-like emboli in the lumina of intestinal, pulmonary and renal blood vessels and severe meningeal haemorrhages. From a forensic pathology perspective, the subcutaneous emphysema of immediate onset after HBOT and the greater severity of the histological lesions in blood vessels, heart, lung and brain differentiate this case from other cases of gas embolism in turtles due to incidental capture. Two factors contributed to this outcome: the existence of a probably unresolved pneumocoelom and the application of HBOT without an initial diagnosis that accurately indicated its use. Therefore, as in human medicine, the use of HBOT in sea turtles with lung lesions and pneumocoelom is discouraged. This is the first description of an iatrogenic gas embolism in a sea turtle.

Spontaneous pneumomediastinum associated with subcutaneous emphysema, pneumopericardium and pneumothorax: a rare association complicating measles.

A unique case of severe measles complicated by multiple features of gas accumulation is described, on the ground of the available literature evidences. Complications from measles have been reported in every organ system and they may vary by age and underlying conditions. Pneumomediastinum is usually associated with subcutaneous emphysema and pneumopericardium, but rarely associated with pneumothorax. We report extremely rare simultaneous occurrence of self-limiting pneumomediastinum, pneumopericardium, subcutaneous neck and chest region emphysema, and pneumothorax, in a 19-year-old girl with measles. A review of the literature has documented only one previous report of spontaneous pneumomediastinum, subcutaneous emphysema and pneumothorax in the course of measles, and no previous cases reported the association of pneumomediastinum, subcutaneous emphysema, pneumopericardium and pneumothorax complicating measles.