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A letter in response to recurrent subcutaneous emphysema in a treated tuberculosis patient: Is there any association?

Ray A - Lung India (2014)

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Critical Care and Sleep Medicine, VMMC and Safdarjang Hospital, New Delhi, India. E-mail: doctoranimeshray@gmail.com.

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Sir, Apropos of the article written by Ete et al. where a female patient with past history of tuberculosis presented with shortness of breath and swelling of face, I would like to furnish the following comments: The patient has been rightly labeled as spontaneous mediastinal emphysema as she developed the mediastinal emphysema during spontaneous breathing (and not on positive pressure breathing)... Now subcutaneous emphysema associated with positive pressure ventilation, palpebral cutaneous tension, palpebral occlusion, airway compromise, dysphagia, dysphonia, pneumoperitoneum etc., has been defined as “severe” or “extensive subcutaneous emphysema”... While fenestrated catheters inserted in the subcutaneous plane act to remove air in subcutaneous tissue directly, the intercostal drainage catheters provide an alternate way for exit of air in the mediastinum (tracking along bronchovascular sheaths from the site of alveolar rupture) through the pleural space rather than into the subcutaneous tissue... But what is important to appreciate is that these methods aim to treat the cosmetic aspect (decreases the subcutaneous emphysema) but has no effect on the underlying air leak which had led to the migration of air to the mediastinum and subcutaneous tissue... Thus, the subcutaneous emphysema would probably recur again as shown in Figure 4... The old history of tuberculosis of the patient, the clinical picture of tracheal deviation and CT picture of parenchymal fibrosis hint to residual damage of lung by tuberculosis... The fact that the shortness of breath in this patient antedated the development of swelling by 2 weeks (the minimal pneumothorax on the CT scan seems unlikely to explain dyspnea in this patient) also might hint at a possible airway involvement... It would be indeed enlightening to know about past symptoms of cough with or without sputum (after resolution of tuberculosis and before the development of severe subcutaneous emphysema), old spirometry suggestive of obstructive airway disease or expiratory CT scans suggestive of air trapping in this patient... Since it is known that post tubercular obstructive airway disease (PTOAD) might occur in more than 30% of pulmonary tuberculosis patients it behooving to consider a diagnosis of PTOAD since it fits the larger picture and might also explain the genesis of air leak in this patient.

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Related in: MedlinePlus

Macklin effect suggests that the air leak caused due to alveolar rupture tracks along the bronchovascular sheath to the mediastinum and then to the subcutaneous tissue along the path of least resistance. Some air may enter the pleural space after rupture of mediastinal pleura
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Figure 1: Macklin effect suggests that the air leak caused due to alveolar rupture tracks along the bronchovascular sheath to the mediastinum and then to the subcutaneous tissue along the path of least resistance. Some air may enter the pleural space after rupture of mediastinal pleura

Mentions: In the letter the authors deliberated on the possible cause for the recurrent subcutaneous emphysema in the patient. In this regard, the pathophysiology of recurrent subcutaneous emphysema can perhaps be explained by the Macklin effect.[4] According to this concept air passing through ruptures in alveoli tracks through bronchovascular sheaths to reach the mediastinum which has somewhat negative pressure with respect to the pressure in the pulmonary parenchyma. Once in the mediastinum the air would further move along tissue planes taking the path of least resistance into the subcutaneous tissue producing subcutaneous emphysema. Some air may rupture through delicate mediastinal fascia to produce pneumothorax. Since the least resistance is offered by the subcutaneous tissue space there is preferential accumulation of air in this space and not in other areas like the pleural space. This is exemplified in this case by the fact that there were minimal pneumothorax but severe subcutaneous emphysema. This is explained in Figure 1.


A letter in response to recurrent subcutaneous emphysema in a treated tuberculosis patient: Is there any association?

Ray A - Lung India (2014)

Macklin effect suggests that the air leak caused due to alveolar rupture tracks along the bronchovascular sheath to the mediastinum and then to the subcutaneous tissue along the path of least resistance. Some air may enter the pleural space after rupture of mediastinal pleura
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4129620&req=5

Figure 1: Macklin effect suggests that the air leak caused due to alveolar rupture tracks along the bronchovascular sheath to the mediastinum and then to the subcutaneous tissue along the path of least resistance. Some air may enter the pleural space after rupture of mediastinal pleura
Mentions: In the letter the authors deliberated on the possible cause for the recurrent subcutaneous emphysema in the patient. In this regard, the pathophysiology of recurrent subcutaneous emphysema can perhaps be explained by the Macklin effect.[4] According to this concept air passing through ruptures in alveoli tracks through bronchovascular sheaths to reach the mediastinum which has somewhat negative pressure with respect to the pressure in the pulmonary parenchyma. Once in the mediastinum the air would further move along tissue planes taking the path of least resistance into the subcutaneous tissue producing subcutaneous emphysema. Some air may rupture through delicate mediastinal fascia to produce pneumothorax. Since the least resistance is offered by the subcutaneous tissue space there is preferential accumulation of air in this space and not in other areas like the pleural space. This is exemplified in this case by the fact that there were minimal pneumothorax but severe subcutaneous emphysema. This is explained in Figure 1.

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Critical Care and Sleep Medicine, VMMC and Safdarjang Hospital, New Delhi, India. E-mail: doctoranimeshray@gmail.com.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Sir, Apropos of the article written by Ete et al. where a female patient with past history of tuberculosis presented with shortness of breath and swelling of face, I would like to furnish the following comments: The patient has been rightly labeled as spontaneous mediastinal emphysema as she developed the mediastinal emphysema during spontaneous breathing (and not on positive pressure breathing)... Now subcutaneous emphysema associated with positive pressure ventilation, palpebral cutaneous tension, palpebral occlusion, airway compromise, dysphagia, dysphonia, pneumoperitoneum etc., has been defined as “severe” or “extensive subcutaneous emphysema”... While fenestrated catheters inserted in the subcutaneous plane act to remove air in subcutaneous tissue directly, the intercostal drainage catheters provide an alternate way for exit of air in the mediastinum (tracking along bronchovascular sheaths from the site of alveolar rupture) through the pleural space rather than into the subcutaneous tissue... But what is important to appreciate is that these methods aim to treat the cosmetic aspect (decreases the subcutaneous emphysema) but has no effect on the underlying air leak which had led to the migration of air to the mediastinum and subcutaneous tissue... Thus, the subcutaneous emphysema would probably recur again as shown in Figure 4... The old history of tuberculosis of the patient, the clinical picture of tracheal deviation and CT picture of parenchymal fibrosis hint to residual damage of lung by tuberculosis... The fact that the shortness of breath in this patient antedated the development of swelling by 2 weeks (the minimal pneumothorax on the CT scan seems unlikely to explain dyspnea in this patient) also might hint at a possible airway involvement... It would be indeed enlightening to know about past symptoms of cough with or without sputum (after resolution of tuberculosis and before the development of severe subcutaneous emphysema), old spirometry suggestive of obstructive airway disease or expiratory CT scans suggestive of air trapping in this patient... Since it is known that post tubercular obstructive airway disease (PTOAD) might occur in more than 30% of pulmonary tuberculosis patients it behooving to consider a diagnosis of PTOAD since it fits the larger picture and might also explain the genesis of air leak in this patient.

No MeSH data available.


Related in: MedlinePlus