Massive surgical emphysema due to coughing at local anesthetic thoracoscopy

Local anesthetic thoracoscopy (LAT) is a popular tri-modality approach used in the investigation and management of unexplained exudative pleural effusions. No international guidelines exist, and practice is widely variable. We describe a case of a patient with an exudative pleural effusion whose radiology was concerning for malignancy. Severe coughing during LAT caused an air leak, massive surgical emphysema (SE) which required a large bore chest drain and a small bore subcutaneous drain. Surgical emphysema eventually settled, and the patient was discharged to start systemic anti-cancer therapy.