Life-threatening Upper Airway Obstruction Caused by Massive Subcutaneous Emphysema during Mechanical Ventilation: A Case Report

Subcutaneous emphysema usually causes pain and swelling, and requires conservative treatment only. We present a case with severe subcutaneous emphysema during positive pressure mechanical ventilation. Life-threatening complications developed in our patient, including intubation difficulty due to upper airway obstruction and occult pneumothorax. We performed an infraclavicular skin incision for decompression, after which endotracheal intubation could be carried out. Computed tomography (CT) after intubation clearly revealed a collapsed extrathoracic upper airway, which was compressed by extremely inflated soft tissue. CT also showed occult pneumothorax not found in the chest X-ray. Occult pneumothorax was also managed by tube thoracostomy. We believe subcutaneous emphysema in mechanically ventilated patients should be considered an alarm sign sometimes deserving of more than conservative treatment.