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Images in paediatrics
Asthma complicated by severe subcutaneous emphysema
  1. Susannah Holt,
  2. David Lee,
  3. Huw Mayberry,
  4. Russell Austin
  1. Department of Womens and Childrens, Wirral University NHS Trust, Upton, UK
  1. Correspondence to Dr Susannah Holt, Department of Womens and Childrens, Wirral University NHS Trust, Upton CH49 5PE, UK; susieholt{at}

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Pneumomediastinum, pneumopericardium and subcutaneous emphysema (SE)1 occur when gas is inappropriately present in anatomical structures. SE is due to the rupture of an alveolus or bronchiole under increased pressure allowing gas to escape extrapleurally. Spontaneous SE (SSE) is associated with acute asthma, aspiration pneumonia and hyaline membrane disease. SSE is uncommon with an incidence of around 1 in 20 000 patients presenting with an exacerbation of asthma.2

A 7-year-old girl presented with a 2-day history of pyrexia, cough and increasing shortness of breath. She was known to have asthma. She developed swollen cheeks alongside increased work of breathing, initially treated as anaphylaxis with no improvement. She had audible bilateral wheeze and a prolonged expiratory phase; during nebulisation, she developed increasing chest wall SE. A chest radiograph (figure 1) showed a small left apical pneumothorax with pneumomediastinum and SE. Peripheral cannulas were inserted and treatment switched to intravenous (IV) salbutamol and magnesium sulfate. She was transferred to our High Dependency Unit (HDU).

Figure 1

Chest radiograph showing subcutaneous emphysema and pneumomediastinum.

Over the next 24 h, IV aminophylline, further magnesium sulfate, IV salbutamol and IV fluids were required. Repeat radiographs showed no worsening of pneumothorax or pneumomediastinum. The SSE became severe with eye closure secondary to periorbital SE and tracking to her wrists and shins (figure 2). She remained well saturated with good blood gas analyses. She did not develop airway compromise.

Figure 2

Photograph showing subcutaneous emphysema affecting face, thorax and abdomen.

A decision was made to manage her conservatively and to wait for the air leak to settle. She demonstrated slow but reassuring resolution of the SE and was discharged by day 6.



  • Contributors SH drafted the case report, which was then revised by DL, HM and RA.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.