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

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.