Abstract
Subcutaneous emphysema, the presence of air under the subcutaneous tissues, often arises in relation to pneumothorax, including iatrogenic pneumothorax. It can arise as a consequence of chest drain insertion and removal. This case report describes worsening of subcutaneous emphysema subsequent to chest drain removal, leading to tardive and life-threatening subcutaneous emphysema. There are few international guidelines describing chest drain removal and there are few reports describing tardive subcutaneous emphysema. These areas need further exploration using evidence-based research in order to develop a consensus on treatment options.