Arch Dis Child: first published as 10.1136/adc.31.156.133 on 1 April 1956. Downloaded from SUBCUTANEOUS EMPHYSEMA COMPLICATING ASTHMA BY J. R. K. HENRY From Hammersmith Hospital, London (RECEIVED FOR PUBLICATION JANUARY 5, 1956) Subcutaneous emphysema complicating asthma She was given adrenaline, 4 minims subcutaneously, is a somewhat rare condition and when first met with crystalline penicillin, 250,000 units six-hourly, 'gantrisin', rather an alarming one. Subcutaneous emphysema 1 g. six-hourly, phenobarbitone, i grain, and oxygen by as a secondary manifestation of trauma of the chest mask immediately. There was some improvement following the sub- wall, fracture of the orbit with escape of air from cutaneous adrenaline, and it was thought that she would the nasal sinuses to the neck and thorax, or on probably settle down and have a good night. However, occasion complicating tracheotomy or thoracentesis, she was restless and vomited three times during the night. is probably more common, and the mechanism The following morning her condition had obviously whereby the air reaches the subcutaneous tissues is deteriorated, and on questioning she admitted to having certainly more easily understood. had a severe pain in the left chest. The respiratory rate Elliott (1938) reports subcutaneous emphysema was now 70 per minute, pulse 170 per minute, and in a woman of 46, developing at the onset of an temperature 1010 F. The cyanosis was more marked asthmatic attack and followed two days later by a and had an unusual maroon tinge. She was obviously in great distress. partial pneumothorax. In this case the sub- On examination there was surgical emphysema copyright. cutaneous emphysema was generalized and was not extending around the neck, over the left chest and axilla, relieved until an incision was made over the chest and down to the left flank. The heart appeared to be wall; whereupon she deflated with a loud hissing normal, the trachea was central, but the movement sound. Field (1943) reports a case of a girl aged of the left chest was reduced and the breath sounds on 4 years 2 months in whom subcutaneous emphysema the left almost absent. complicated an acute attack of asthma. In this A radiograph of the chest (Fig. 1) showed that both case the emphysema subsided, but 12 days later she lungs were well expanded, and that there was marked developed a spontaneous pheumothorax and massive surgical emphysema in the neck, the left axilla and in the http://adc.bmj.com/ mediastinum. She was given 'nepenthe', 8 minims, and collapse. put in an oxygen tent. Case Report Her general condition improved almost immediately. A girl aged 6 years 2 months was admitted to hospital Half-an-hour later her respiration rate had fallen to as an emergency on October 22 with an attack of asthma. 50 per minute and four hours later was 20 per minute. She had been having minor attacks of asthma, lasting The surgical emphysema did not increase in degree, but approximately half-an-hour and subsiding without the following day had spread to the right chest. It then treatment, since the age of 16 months. During the last gradually subsided and in six days had entirely gone. on September 30, 2021 by guest. Protected three months, the attacks had been more frequent and On discharge seventeen days after admission she was had lasted longer. The present attack had started on very well and the chest was clinically and radiologically waking on the morning of admission; it was more severe clear (Fig. 2). than any she had had previously, and when she was seen was of some eight hours' duration. Discussion Apart from frequent tonsillitis, she had had no previous illness, or eczema during infancy. Her paternal grand- It seems well established that for air to reach the father had asthma. subcutaneous tissues from the lungs in this type of On admission she looked ill, and the lips were case it must first reach the mediastinum. Once it cyanosed. There was audible expiratory wheezing it via the neck to (temperature 100-40 F., respirations 60 per minute, has reached there may proceed pulse 160). On examination of the chest the movements any part of the body, as there is no anatomical were equal but poor, the trachea central. The breath barrier to stop its advance. sounds were harsh, and there were sibilant rhonchi pre- The mechanism within the lung has been well dominantly expiratory over both lung fields. investigated by Macklin (1939) by introducing a 133 l0A Arch Dis Child: first published as 10.1136/adc.31.156.133 on 1 April 1956. Downloaded from 134 ARCHIVES OF DISEASE IN CHILDHOOD FiG. 1.-Chest radiograph taken on the morning after admission, FIG. 2.-Chest radiograph 17 days after admission, showing complete showing marked surgcal emphysema. absorption of the surgical emphysema. copyright. catheter into a region of an animal's lung and over- asthma made a complete recovery, the emphysema distending the alveoli. He found that the air leak disappearing in from two to 21 days. The ages of was due to multiple and very fine ruptures in the these patients ranged from 3 to 38 years. alveolar bases, and that the escaping air travelled The treatment of our case consisted of antibiotics. along artificial tunnels formed in the vascular This is important because the artificial channels sheaths. Further, within the lung it may take one made by the air escaping from the ruptured alveoli or both of two routes: (1) To the mediastinum, from make excellent pathways for bacteria to reach the which there may be serious consequences, owing to lung parenchyma and the mediastinum. Secondly, http://adc.bmj.com/ an interference with the pulmonary blood flow due sedation; 8 minims of 'nepenthe' intramuscularly to the increased pressure in the perivascular sheaths was sufficient, and great improvement followed at the root. It seems reasonable to suppose that it. This immediately brings up the question of this was the cause of the sudden increase of dys- whether 'nepenthe' should be given to patients pnoea and tachypnoea of our patient, and that the having an asthmatic attack; certainly in this aching pain complained of during the night was type of case it seems to be indicated. Oxygen ischaemic in nature and secondary to a partial was given, partly as the cyanosis and respiratory on September 30, 2021 by guest. Protected occlusion of the pulmonary blood flow. (2) The distress warranted it, but also with the idea that escaping air may equally track peripherally, and if the subcutaneous air consisted mostly of oxygen here form a bulla beneath the visceral pleura, and it would absorb more quickly than if the nitrogen it seems reasonable too to suppose that rupture of content were high. There was no need to remove a bulla so formed may be the cause of a spontaneous the air artificially, as the emphysema was not pneumothorax which occasionally complicates an massive and absorbed quickly. However, in cases acute attack of asthma without there being sub- where there is extrene subcutaneous emphysema, cutaneous emphysema, or of the spontaneous an incision is more likely to have the desired effect pneumothorax which may occur at a variable time than attempting to aspirate. Finally, if the side after the appearance of subcutaneous emphysema from which the air is escaping can be localized, the as in Field's case. induction of an artificial pneumothorax on that side, The prognosis of this condition seems to be good, with the object of collapsing the lung and so pre- and in a review of the literature by Rosenberg (1938), venting further escape of air from the alveoli would 18 cases of subcutaneous emphysema complicating seem to be a logical form of treatment. Arch Dis Child: first published as 10.1136/adc.31.156.133 on 1 April 1956. Downloaded from SUBCUTANEOUS EMPHYSEMA COMPLICATING ASTHMA 135 I wish to thanik Dr. Cbarle Newman for permission to report this case, and for the help and encoragement A case is reported of a girl aged 6 years 2 months he gave me in prearng paper. who showed subcutaneous emphysema complicating REFEN an attack of asthma. The probable nehanisms Eiliot, R. W. (1938). LAmcet, 1. 1104. likely complications and methods of treatment are Fl, C. EP (1943). Ardhs of Disease in Chdhood, 15, 197. Macklmi C. C. (1939). Arch. intern. Med., 4, 913. discuse Rosenberg, L. d R J. (1938). Amer. J. med. Sci., V5, 682. copyright. http://adc.bmj.com/ on September 30, 2021 by guest. Protected i*B.