A 42-year-old male got admitted with COVID-19 related acute respiratory distress syndrome (ARDS). A Portex 7.5 French triple lumen catheter was placed in the right subclavian vein and trachea was intubated using a 7.5 mm endotracheal tube Rusch. On administering high positive end expiratory pressure ventilation, he developed subcutaneous emphysema over chest which progressed to the right side of his face involving the right orbit [Fig. 1a]. On examination, palpable crepitus was noted in the periocular region with subconjunctival collection of air [Fig. 1b]. Direct and consensual pupillary reflexes were normal. Bilateral intercostal drainage tubes were placed [Fig. 1c]. The emphysema spontaneously resolved in the following 2 days.
Figure 1.
(a) Clinical picture showing swelling of the right side of the face along with upper and lower eyelid fullness. (b) Clinical picture showing presence of subconjunctival air. (c) Chest radiogram showing subcutaneous emphysema, 2 chest drainage tubes in situ, central line in situ, and lung parenchymal disease
Orbital emphysema usually occurs after trauma and resolve spontaneously.[1] They are of three types: Palpebral, True, and Orbito-palpebral.[2] However, spontaneous orbital emphysema in COVID-19 ARDS has also been reported.[3] Subcutaneous emphysema of thorax develops from pneumothorax barotrauma in a mechanically ventilated patient, and then air migrates to the orbit.[4] Unilaterality in this case is because the patient was lying on a left lateral position.
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