The Occurrence of Extensive Subcutaneous Emphysema and Pneumothorax after Endotracheal Tube Removal: A Case Report
Abstract
Both pneumothorax and subcutaneous emphysema (SCE) after extubation are very rare. Pneumothorax occurs due to lung structure rupture, whereas SCE develops if an air leak persists. In this case report, we describe a patient with stone aspiration who developed severe SCE and pneumothorax after extubation. The patient was a 5-year-old Iranian boy of Baluch ethnicity who had accidentally aspirated a stone. The otolaryngologist
attempted removal via bronchoscopy but was unsuccessful and ordered the patient’s transfer to a better-equipped center. We attempted to extubate the patient before his transfer; however, after the endotracheal tube was removed, he developed severe SCE. As a result, we had to re-intubate the patient and place him on mechanical ventilation. Pneumothorax is an underappreciated complication of foreign body aspiration
(FBA) that can occur even in the absence of high-pressure ventilation. The timing of pneumothorax development can be unpredictable, and clinicians should maintain a high level of suspicion for quick diagnosis and treatment.
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removal of a bronchial foreign body in a child. Med Lasers. 2020;9(1):65-70. https://doi.org/10.25289/ML.2020.9.1.65
[3] Shostak E. Foreign body removal in children and adults: review of available techniques and emerging technologies. AME Med J. 2018;3:75. https://doi.org/10.21037/amj.2018.07.02
[4] Chiu CY, Wong KS, Lai SH, Hsia SH, Wu CT. Factors predicting early diagnosis of foreign body aspiration in children. Pediatr Emerg Care. 2005;21(3):161-4.
[5] Skoulakis CE, Doxas PG, Papadakis CE, Proimos E, Christodoulou P, Bizakis JG, et al. Bronchoscopy for foreign body removal in children. A review and analysis of 210 cases. Int J Pediatr Otorhinolaryngol. 2000;53(2):143-8. https://doi.org/10.1016/S0165-5876(00)00324-4
[6] Gómez-Ramos JJ, Marín-Medina A, Castillo-Cobian AA, Felipe-Diego OG. Successful management foreign body
aspiration associated with severe respiratory distress and subcutaneous emphysema: case report and literature review.
Medicina (Kaunas). 2022;58(3):396. https://doi.org/10.3390/medicina58030396
[7] Rahat Dahmardeh A, Keykha A. Large pneumothorax associated with mechanical ventilation in patients with chronic respiratory disease. Arch Anesthesiol Crit Care. 2024;11(2):247-55. https://doi.org/10.18502/aacc.
v11i2.17973
[8] Dias RJ, Dave NM, Chaskar VP, Garasia MB. Late onset pneumothorax following bronchoscopic foreign body removal. J Anaesthesiol Clin Pharmacol. 2017;33(2):280-2. https://doi.org/10.4103/0970-9185.173378
[9] Tbini M, Hafyene A, Ben Ammar C, El Bessi S, Ben Salah M. Pneumothorax following rigid bronchoscopy for
foreign body removal in a child: a case report. Int J Surg Case Rep. 2024;124:110361. https://doi.org/10.1016/j.
ijscr.2024.110361
[10] Newby MD, Thomas D, Mullett CJ, Vijay C, Carr MM. Foreign body aspiration presenting as pneumothorax in a child. Cureus. 2020;12(5):e8161. https://doi.org/10.7759/cureus.8161
[11] Lowe DA, Vasquez R, Maniaci V. Foreign body aspiration in children. Clin Pediatr Emerg Med. 2015;16(3):140-8.
https:// doi.org/10.1016/j.cpem.2015.07.002
[12] Amaniti E, Provitsaki C, Papakonstantinou P, Tagarakis G, Sapalidis K, Dalakakis I, et al. Unexpected tension
pneumothorax-hemothorax during induction of general anaesthesia. Case Rep Anesthesiol. 2019;2019:5017082.
https://doi.org/10.1155/2019/5017082
[13] Okonkwo OC, Simons A, Nichani J. Paediatric airway foreign body - the human factors influencing patient safety in our hospitals. Int J Pediatr Otorhinolaryngol. 2016;91:100-4. https://doi.org/10.1016/j.ijporl.2016.10.016
[14] Bajaj D, Sachdeva A, Deepak D. Foreign body aspiration. J Thorac Dis. 2020;13(8):5159-75. https://doi.org/10.21037/
jtd.2020.03.94
[15] Sarkar A, Murthy V. Foreign body aspiration: a review of current strategies for management. Shanghai Chest.
2020;5:38. https://doi.org/10.21037/shc-20-38
[16] Hatziagorou E, Kirvassilis F, Ntaflos A, Skouras A, Kontzoglou G, Tsanakas J. Foreign body removal by flexible
bronchoscopy using retrieval basket in children. Eur Respir J. 2020;56(Suppl 64):3512. https://doi.org/10.1183/13993003.
congress-2020.3512
[17] Kim K, Lee HJ, Yang EA, Kim HS, Chun YH, Yoon JS, et al. Foreign body removal by flexible bronchoscopy using retrieval basket in children. Ann Thorac Med. 2018;13(2):82-5. https://doi.org/10.4103/atm.ATM_337_17
[18] Nunes Caldeira J, Fernandes L, Rodrigues Sousa S, Martins Y, Barata F. Flexible bronchoscopy as the first-line strategy for extraction of tracheobronchial foreign bodies. Open Respir Arch. 2022;4(3):100174. https://doi.org/10.1016/j.opresp.2022.100174
[19] Ramos-Rossy J, Cantres O, Torres A, Casal J, Otero Y, ArzonNieves G, et al. Flexible bronchoscopic removal of 3 foreign objects. Fed Pract. 2018;35(9):24-6.
[20] Sedman A, Harris JM 2nd, Schulz K, Schwalenstocker E, Remus D, Scanlon M, et al. Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for children’s hospitals. Pediatrics. 2005;115(1):135-45. https://doi. org/10.1542/peds.2004-1083
[21] Furia S, Breda C. Primary spontaneous pneumothorax in children and adolescents: a systematic review. Pediatr Med.
2019;2:1. https://doi.org/10.21037/pm.2019.04.01
[22] da Silva PSL, de Aguiar VE, Fonseca MCM. Iatrogenic pneumothorax in mechanically ventilated children: incidence,
risk factors and other outcomes. Heart Lung. 2015;44(3):238- 42. https://doi.org/10.1016/j.hrtlng.2015.01.005
[23] Kumar S, Kabi A, Bamba C. Post-operative pneumothorax with subcutaneous emphysema in a pre-eclamptic patient. Indian J Anaesth. 2016;60(7):527-8. https://doi.org/10.4103/0019- 5049.186024
[24] Hsu CW, Sun SF. Iatrogenic pneumothorax related to mechanical ventilation. World J Crit Care Med.
2014;3(1):8- 14. https://doi.org/10.5492/wjccm.v3.i1.8
[25] Hu M, Green R, Gungor A. Pneumomediastinum and subcutaneous emphysema from bronchial foreign body
aspiration. Am J Otolaryngol. 2013;34(1):85-8. https://doi.org/10.1016/j.amjoto.2012.09.005
[26] Huang Y, Huang H, Li Q, Browning RF, Parrish S, Turner JF Jr, et al. Approach of the treatment for pneumothorax. J Thorac Dis. 2014;6(Suppl 4):S416-20.
[27] Gruber M, van Der Meer G, Ling B, Barber C, Mills N, Neeff M, et al. The bacterial species associated with aspirated foreign bodies in children. Auris Nasus Larynx. 2018;45(3):598-602. https://doi.org/10.1016/j.anl.2017.07.014
[28] Bai AD, Srivastava S, Digby GC, Girard V, Razak F, Verma AA. Anaerobic antibiotic coverage in aspiration pneumonia and the associated benefits and harms: a retrospective cohort study. Chest. 2024;166(1):39-48. https://doi.org/10.1016/j.chest.2024.02.025
[2] Mun IK, Ju YR, Lee SJ, Woo SH. A case of bilateral tension pneumothorax after the successful CO2 laser-assisted
removal of a bronchial foreign body in a child. Med Lasers. 2020;9(1):65-70. https://doi.org/10.25289/ML.2020.9.1.65
[3] Shostak E. Foreign body removal in children and adults: review of available techniques and emerging technologies. AME Med J. 2018;3:75. https://doi.org/10.21037/amj.2018.07.02
[4] Chiu CY, Wong KS, Lai SH, Hsia SH, Wu CT. Factors predicting early diagnosis of foreign body aspiration in children. Pediatr Emerg Care. 2005;21(3):161-4.
[5] Skoulakis CE, Doxas PG, Papadakis CE, Proimos E, Christodoulou P, Bizakis JG, et al. Bronchoscopy for foreign body removal in children. A review and analysis of 210 cases. Int J Pediatr Otorhinolaryngol. 2000;53(2):143-8. https://doi.org/10.1016/S0165-5876(00)00324-4
[6] Gómez-Ramos JJ, Marín-Medina A, Castillo-Cobian AA, Felipe-Diego OG. Successful management foreign body
aspiration associated with severe respiratory distress and subcutaneous emphysema: case report and literature review.
Medicina (Kaunas). 2022;58(3):396. https://doi.org/10.3390/medicina58030396
[7] Rahat Dahmardeh A, Keykha A. Large pneumothorax associated with mechanical ventilation in patients with chronic respiratory disease. Arch Anesthesiol Crit Care. 2024;11(2):247-55. https://doi.org/10.18502/aacc.
v11i2.17973
[8] Dias RJ, Dave NM, Chaskar VP, Garasia MB. Late onset pneumothorax following bronchoscopic foreign body removal. J Anaesthesiol Clin Pharmacol. 2017;33(2):280-2. https://doi.org/10.4103/0970-9185.173378
[9] Tbini M, Hafyene A, Ben Ammar C, El Bessi S, Ben Salah M. Pneumothorax following rigid bronchoscopy for
foreign body removal in a child: a case report. Int J Surg Case Rep. 2024;124:110361. https://doi.org/10.1016/j.
ijscr.2024.110361
[10] Newby MD, Thomas D, Mullett CJ, Vijay C, Carr MM. Foreign body aspiration presenting as pneumothorax in a child. Cureus. 2020;12(5):e8161. https://doi.org/10.7759/cureus.8161
[11] Lowe DA, Vasquez R, Maniaci V. Foreign body aspiration in children. Clin Pediatr Emerg Med. 2015;16(3):140-8.
https:// doi.org/10.1016/j.cpem.2015.07.002
[12] Amaniti E, Provitsaki C, Papakonstantinou P, Tagarakis G, Sapalidis K, Dalakakis I, et al. Unexpected tension
pneumothorax-hemothorax during induction of general anaesthesia. Case Rep Anesthesiol. 2019;2019:5017082.
https://doi.org/10.1155/2019/5017082
[13] Okonkwo OC, Simons A, Nichani J. Paediatric airway foreign body - the human factors influencing patient safety in our hospitals. Int J Pediatr Otorhinolaryngol. 2016;91:100-4. https://doi.org/10.1016/j.ijporl.2016.10.016
[14] Bajaj D, Sachdeva A, Deepak D. Foreign body aspiration. J Thorac Dis. 2020;13(8):5159-75. https://doi.org/10.21037/
jtd.2020.03.94
[15] Sarkar A, Murthy V. Foreign body aspiration: a review of current strategies for management. Shanghai Chest.
2020;5:38. https://doi.org/10.21037/shc-20-38
[16] Hatziagorou E, Kirvassilis F, Ntaflos A, Skouras A, Kontzoglou G, Tsanakas J. Foreign body removal by flexible
bronchoscopy using retrieval basket in children. Eur Respir J. 2020;56(Suppl 64):3512. https://doi.org/10.1183/13993003.
congress-2020.3512
[17] Kim K, Lee HJ, Yang EA, Kim HS, Chun YH, Yoon JS, et al. Foreign body removal by flexible bronchoscopy using retrieval basket in children. Ann Thorac Med. 2018;13(2):82-5. https://doi.org/10.4103/atm.ATM_337_17
[18] Nunes Caldeira J, Fernandes L, Rodrigues Sousa S, Martins Y, Barata F. Flexible bronchoscopy as the first-line strategy for extraction of tracheobronchial foreign bodies. Open Respir Arch. 2022;4(3):100174. https://doi.org/10.1016/j.opresp.2022.100174
[19] Ramos-Rossy J, Cantres O, Torres A, Casal J, Otero Y, ArzonNieves G, et al. Flexible bronchoscopic removal of 3 foreign objects. Fed Pract. 2018;35(9):24-6.
[20] Sedman A, Harris JM 2nd, Schulz K, Schwalenstocker E, Remus D, Scanlon M, et al. Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for children’s hospitals. Pediatrics. 2005;115(1):135-45. https://doi. org/10.1542/peds.2004-1083
[21] Furia S, Breda C. Primary spontaneous pneumothorax in children and adolescents: a systematic review. Pediatr Med.
2019;2:1. https://doi.org/10.21037/pm.2019.04.01
[22] da Silva PSL, de Aguiar VE, Fonseca MCM. Iatrogenic pneumothorax in mechanically ventilated children: incidence,
risk factors and other outcomes. Heart Lung. 2015;44(3):238- 42. https://doi.org/10.1016/j.hrtlng.2015.01.005
[23] Kumar S, Kabi A, Bamba C. Post-operative pneumothorax with subcutaneous emphysema in a pre-eclamptic patient. Indian J Anaesth. 2016;60(7):527-8. https://doi.org/10.4103/0019- 5049.186024
[24] Hsu CW, Sun SF. Iatrogenic pneumothorax related to mechanical ventilation. World J Crit Care Med.
2014;3(1):8- 14. https://doi.org/10.5492/wjccm.v3.i1.8
[25] Hu M, Green R, Gungor A. Pneumomediastinum and subcutaneous emphysema from bronchial foreign body
aspiration. Am J Otolaryngol. 2013;34(1):85-8. https://doi.org/10.1016/j.amjoto.2012.09.005
[26] Huang Y, Huang H, Li Q, Browning RF, Parrish S, Turner JF Jr, et al. Approach of the treatment for pneumothorax. J Thorac Dis. 2014;6(Suppl 4):S416-20.
[27] Gruber M, van Der Meer G, Ling B, Barber C, Mills N, Neeff M, et al. The bacterial species associated with aspirated foreign bodies in children. Auris Nasus Larynx. 2018;45(3):598-602. https://doi.org/10.1016/j.anl.2017.07.014
[28] Bai AD, Srivastava S, Digby GC, Girard V, Razak F, Verma AA. Anaerobic antibiotic coverage in aspiration pneumonia and the associated benefits and harms: a retrospective cohort study. Chest. 2024;166(1):39-48. https://doi.org/10.1016/j.chest.2024.02.025
| Files | ||
| Issue | Vol 9 No 6 (2024): November-December | |
| Section | Case Report(s) | |
| DOI | https://doi.org/10.18502/crcp.v9i6.18949 | |
| Keywords | ||
| Pneumothorax Mechanical ventilation Subcutaneous emphysema Foreign body aspiration Respiratory aspiration | ||
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How to Cite
1.
Rahat Dahmardeh A, Keykha A. The Occurrence of Extensive Subcutaneous Emphysema and Pneumothorax after Endotracheal Tube Removal: A Case Report. CRCP. 2025;9(6):281-288.
