# Extensive Surgical Emphysema and Pneumomediastinum Following Chest Drain Insertion in a Patient With Bullous Chronic Obstructive Pulmonary Disease (COPD): A Case Report

## TL;DR

An elderly COPD patient developed severe surgical emphysema and pneumomediastinum after a chest drain insertion, highlighting risks in patients with fragile lung tissue.

## Contribution

This case report highlights a rare but severe complication of chest drain insertion in patients with bullous COPD.

## Key findings

- The patient developed extensive surgical emphysema and pneumomediastinum after chest drain insertion.
- CT imaging showed bilateral pneumothoraces and diffuse bullous emphysema.
- The complication was likely due to rupture of pre-existing bullae and air tracking through tissue planes.

## Abstract

Subcutaneous (surgical) emphysema and pneumomediastinum are recognized complications of thoracic procedures. They are often self-limiting but may occasionally indicate serious underlying pathology or precipitate life-threatening deterioration, particularly in patients with chronic obstructive pulmonary disease (COPD) and bullous lung disease. We present the case of an 87-year-old male patient with known COPD who was admitted with worsening dyspnoea and a productive cough. Imaging revealed a large left-sided pneumothorax, and emergency needle decompression followed by intercostal chest drain insertion was performed. Shortly after the procedure, the patient developed extensive surgical emphysema extending from the face to the upper abdominal wall. Computed tomography (CT) of the thorax demonstrated bilateral pneumothoraces, severe pneumomediastinum, and diffuse bullous emphysema. Despite supportive measures and multidisciplinary discussion, the patient’s condition deteriorated, and care was redirected toward comfort measures in line with his wishes. This case highlights a severe complication of chest drain insertion in a patient with bullous COPD, likely precipitated by rupture of pre-existing bullae and air tracking through tissue planes. Awareness of this risk, meticulous procedural technique, and early post-procedure imaging are critical. Even standard thoracic interventions can result in catastrophic complications in patients with fragile lung parenchyma, emphasizing the need for vigilant monitoring and multidisciplinary management.