Subcutaneous Emphysema (Air in the Subcutaneous Tissues)

1. Identify and treat the underlying cause (primary step)

• Presume an underlying pneumothorax in any patient with subcutaneous emphysema, even if the chest x-ray doesn't show one — point-of-care ultrasound (POCUS) is more sensitive than plain film for detecting it (Tintinalli's Emergency Medicine, p. subcutaneous emphysema section).
• If the patient needs intubation/positive-pressure ventilation, a chest tube should be placed on the involved side first, since positive pressure can rapidly worsen a occult pneumothorax.
• If SE is extensive or severe, suspect a major tracheobronchial, laryngeal, pharyngeal, or esophageal injury and work it up further (bronchoscopy, CT, esophagography as indicated).
• If a chest tube is already in place but not controlling the leak, ensure it isn't kinked/malpositioned, upsize to a larger-bore tube, or add suction.

2. Mild to moderate cases — conservative management

• Bed rest and reassurance
• Analgesia for discomfort
• Supplemental high-flow oxygen (up to ~95-100% FiO2 via non-rebreather or oxygen concentrator) — this creates a "nitrogen washout" gradient that speeds reabsorption of the trapped gas, even without treating hypoxia directly
• Monitoring for signs of airway compromise, respiratory distress, or expanding emphysema (serial exams, imaging)
• Treating any predisposing factor (e.g., avoiding further positive-pressure ventilation strain, treating the pneumothorax, stopping an air-generating procedure)

3. Severe, rapidly progressive, or massive SE — active decompression

• "Blow-hole" skin incisions — small infraclavicular or chest wall incisions that let trapped air vent to the surface
• Subcutaneous angio-catheters or tunneled/large-bore fenestrated subcutaneous drains on low continuous suction — a safe, effective option described in multiple case series for extensive or "massive" SE
• Multisite subcutaneous drainage
• Increasing suction on an existing chest tube
• Negative pressure wound therapy dressings have also been reported for severe cases
• Emergency tracheostomy or airway securing if there is impending airway obstruction from massive neck/facial emphysema (rare, extreme cases)

Special notes

• After thoracic surgery (e.g., lobectomy), SE is more common in patients with poor pulmonary function, steroid use, or prolonged air leak, and can prolong hospital stay.
• In dental/maxillofacial cases (air forced into submucosal facial spaces during procedures), management is usually conservative reassurance and monitoring; broad-spectrum antibiotics are sometimes given if there's an open mucosal lesion risking bacterial contamination, and patients are watched for respiratory distress before discharge.
• Avoid unnecessary positive pressure maneuvers (e.g., excessive bag-valve-mask force) that could worsen the leak while the underlying cause is being addressed.