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Critical Situations
May 1998

Subcutaneous Emphysema: Air as a Cause of Disease

Arch Dermatol. 1998;134(5):557-559. doi:10.1001/archderm.134.5.557

A 78-year-old white man with a 100 pack-year history of smoking and long-standing chronic obstructive pulmonary disease presented to the health clinic at the US Soldier's and Airmen's Home complaining of pain in his left arm and chest pain that worsened with arm movement. His medical history was also significant for chronic renal insufficiency, hypertension, hypothyroidism, and peripheral vascular disease. The presenting symptoms began earlier that day as a sore throat and dysphagia, which progressed to the point in which he had difficulty breathing and took several puffs of his albuterol inhaler, with some relief. On presentation to the US Soldier's and Airmen's Home clinic he was noted to have subcutaneous swelling of the chest, neck, and face. He also began to feel dyspneic and lightheaded and was then transferred to the emergency department at the Walter Reed Army Medical Center, Washington, DC. By that time, the patient appeared ill, with obvious swelling of the chest, upper extremity, and face. His temperature was 36°C; respirations, 18/min, pulse rate, 65/min; blood pressure, 118/60 mm Hg; and oxygen saturation 92% on 6 L of oxygen via nasal cannula. Results of the physical examination were significant for gross proximal left upper extremity and chest wall, neck, and facial skin distention (Figure 1), especially pronounced in the right periorbital region (Figure 2). When these areas were palpated, crepitations were appreciated. Auscultation of the chest revealed crackles that varied with respiration but were synchronous with the heart beat. Breath sounds were markedly decreased on the left side. His eyes were nearly closed because of the progressive periorbital swelling.