PMC2627309_01
Portable roentogram obtained shortly after the acute onset of chest pain, tachypnea, and desaturation. Significant pneumothorax is evident (white arrow). Multiple attempts at needle decompression were performed without success prior to chest tube insertion.
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F1
Portable roentogram revealed a large right-sided pneumothorax (Fig 1).
Computed tomography imaging at the second intercostal space shortly after chest tube insertion demonstrating subcutaneous emphysema due to persistent air leak originating from sites of repeated needle thoracostomy attempts (white arrow). The air leak was exacerbated by high peak airway pressures required to maintain oxygenation and ventilation.
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F2
A sizable continuous air leak was noted upon chest tube insertion, as was a considerable amount of right anterior chest subcutaneous emphysema (SE) that tracked inferiorly from the infraclavicular sites of repeated attempts at needle thoracostomy (Figs 2 and 3a).
(a) Portable roentogram shortly after right tube thoracostomy following repeated unsuccessful attempts at needle thoracostomy demonstrates rapid development of extensive subcutaneous emphysema in conjunction with positive pressure ventilation and persistent chest tube air leak. (b) Computed tomography scout film approximately 12 hours after tube thoracostomy demonstrates wide extension and severe degree of subcutaneous emphysema (white arrows). Prepectoral "blowhole" incision (black arrow).
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F3
A sizable continuous air leak was noted upon chest tube insertion, as was a considerable amount of right anterior chest subcutaneous emphysema (SE) that tracked inferiorly from the infraclavicular sites of repeated attempts at needle thoracostomy (Figs 2 and 3a). No appreciable change in body contour or crepitance was noted over the next 48 hours; however, the patient's severe SE, which had tracked inferiorly into the abdominal subcutaneous tissues, had stabilized (Fig 3b).
Portable roentogram demonstrates resolution of subcutaneous emphysema approximately 48 hours following application of topical negative pressure wound therapy dressing (white arrow).
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F4
A topical negative pressure wound therapy (NPWT) dressing (VAC dressing, KCI International, San Antonio, Tex) was inserted into the blowhole incision and set at a continuous suction of 100 mm Hg (Fig 4).
Representative saggital computed tomography scan images of the chest at the level of the sternoclavicular joint (a) and the top of the aortic arch (b)taken shortly after tube thoracostomy. Note the extensive bilateral subcutaneous emphysema. Corresponding sections after 48 hours of NPWT (c, d, respectively) demonstrate near-complete resolution of SE.
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F5
Over the subsequent 48 hours. there was near-complete resolution of SE as supported by physical examination and repeat computed tomography scan (Fig 5).