Pneumomediastinum: Difference between revisions

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==Background==
==Background==
*usually occurs with sudden increase in intra-alveolar pressure causing alveolar rupture, air dissects into pulmonary interstitium and then into mediastinum, neck, or pericardium
[[File:Body Cavities Frontal view labeled 2.jpg|thumb|The pericardial cavity in this image is labeled d and is part of the inferior mediastium. Here we can see its relation to the superior mediastinum a, the pleural cavities c, and the diaphragm e.]]
*life threatening cause is esophageal rupture
[[File:Gray968.png|thumb|A transverse section of the thorax, showing the contents of the middle and the posterior mediastinum.]]
*if no hemodynamic or airway compromise present, spontaneous pneumomediastinum is not a life threatening condition 
*Also known as mediastinal emphysema
*Definition: presence of free air in the mediastinum
*Can be Spontaneous or secondary (to violation of aerodigestive tract)<ref name="Bakhos">Bakhos CT, Pupovac SS, Ata A, et al. Spontaneous pneumomediastinum: an extensive workup is not required. J Am Coll Surg. 2014 Oct;219(4):713-7. doi: 10.1016/j.jamcollsurg.2014.06.001.</ref>
*Spontaneous pneumomediastinum usually occurs due to sudden increase in intra-alveolar pressure causing alveolar rupture → air dissects into pulmonary interstitium and then into mediastinum, neck, or pericardium<ref name="Niehaus">Niehaus M, Rusgo A, Roth K, Jacoby JL. Retropharyngeal air and pneumomediastinum: a rare complication of influenza A and asthma in an adult. Am J Emerg Med. 2015 Jun 14. pii: S0735-6757(15)00495-7. doi: 10.1016/j.ajem.2015.06.020.</ref>
*Life threatening causes include [[esophageal rupture]] or [[tension pneumothorax]]


==Causes==
===Etiology<ref>Kouritas VK, et al. Pneumomediastinum. J Thorac Dis. 2015 Feb; 7(Suppl 1): S44–S49. doi: 10.3978/j.issn.2072-1439.2015.01.11</ref>===
*illegal drug use
====Primary (i.e. Spontaneous)====
*No identified cause
*Smoking or tobacco use
*Recreational drug inhalation ([[cocaine]], [[methamphetamine]], [[marijuana]])<ref name="Johnson">Johnson JN, Jones R, Wills BK. Spontaneous Pneumomediastinum. Western Journal of Emergency Medicine. 2008;9(4):217-218.</ref>


#inhaling cocaine
====Secondary====
#smoking cocaine
*Intrinsic Lung and Airway
#smoking marijuana
**[[Asthma]] / [[COPD]] (most common co-morbidity<ref name="Bakhos" />)
**Bronchiectasis
**Interstitial lung disease
**Lung cancer
**[[Foreign body in the airway]]
**[[Mycoplasma pneumoniae]] [[pneumonia]]
**[[Influenza]] A<ref name="Niehaus" />
*Iatrogenic
**Endoscopy, bronchoscopy, or colonoscopy
**[[Intubation]]
**Central venous access procedures
**Thoracostomy / VATS
**Chest or abdominal surgeries
*Traumatic
**[[Thoracic trauma]] (blunt or penetrating)
**[[Blast injury]]
**Environmental [[pulmonary barotrauma]] (e.g. [[Scuba diving emergencies|scuba diving]], [[Commercial in-flight medical emergencies|flight]])
*Other
**Excessive vomiting (i.e., [[Boerhaave syndrome]], [[anorexia nervosa]])
**[[Esophageal rupture]] (rare)
**[[Hydrocarbons|Hydrocarbon]] inhalation
**Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest)
**[[Childbirth]]


*vomiting
==Clinical Features==
*retching
*[[Chest pain]]
*asthma
*[[Dyspnea]]
*coughing
*[[Subcutaneous emphysema]], especially of face, neck, and chest.<ref>Quresi SA, Tilyard A (2008). "Unusual Presentation of Spontaneous Mediastinum: A Case Report". ''Cases Journal'' 1:349. doi:10.1186/1757-1626-1-349</ref>
*esophageal rupture
*Voice change, [[cough]], [[stridor]]
*recent endoscopy
*"Crunching" sound on auscultation during systole (Hamman's crunch)
*trauma
*Severe cases (generally after trauma) may mimic [[cardiac tamponade]]<ref>Beg MH, Reyazuddin, Ansari MM (1988). "Traumatic tension Pneumomediastinum Mimicking Cardiac Tamponade".  ''Thorax'' 43:576-677. doi: 10.1136/thx.43.7.576.</ref><ref>Jennings S, Peeceeyen S, Horton M. Tension pneumomediastinum after blunt chest trauma. ANZ J Surg. 2015 Jan;85(1-2):90-1. doi: 10.1111/ans.12378.</ref>
**Search for other more serious injuries (larynx, bronchus, esophagus)


==Clinical Features==
==Differential Diagnosis==
*chest pain
{{Template:Chest Pain DDX}}
**voice change, cough, stridor
 
*subQ&nbsp;emphysema in chest wall, neck, face, abdomen, scrotum
{{Thoracic trauma DDX}}
*"Hamman's Crunch" - crunching sound of heart during systole


==Workup==
==Evaluation==
*ABCs
[[File:PMC3047855 12245 2010 205 Fig1 HTML.png|thumb|Pneumomediastinum from nasal insufflation of cocaine.]]
*CXR
[[File:PneumoMediastinum2008.jpg|thumb|Traumatic pneumomediastinum and right sided pneumothorax with first rib fracture.]]
*Rule-out esophageal rupture by hx and exam or with esophagoscopy if indicated
[[File:Pneumomediastinum-003.jpg|thumb|Pneumomediastinum with Angel wing sign]]
[[File:Subcutaneous emphysema chest cropped.jpg|thumb|Pneumomediastinum with subcutanous emphysema on CT.]]
*CT Chest (preferred diagnostic test)
*[[CXR]]
**AP/PA - Ring around right pulmonary artery, air along left heart border, air in upper chest/neck soft tissue
**Lateral - air along anterior heart border
**Lateral neck - may see mediastinal air in neck
**30% with spontaneous pneumomediastinum will have normal CXR<ref name="Bakhos" />


==Management==
==Management==
*supportive
*Supportive care<ref name="Johnson" />
*no specific therapy for spontaneous pneumomediastinum
**Pneumomediastinum typically reabsorbs over 1-2 weeks.
*treat underlying cause
*Treat underlying cause, if identified


==Disposition==
==Disposition==
*depends on underlying cause and severity of condition
===Primary (Spontaneous)===
*most pt's with spontaneous pneumomediastinum, not caused by trauma or&nbsp;esophageal rupture, can&nbsp;be safely discharged
*Benign and self-limited disease
*Generally does not require repeat imaging, and can be managed conservatively on an outpatient basis with follow up in 24 to 48 hours<ref name="Bakhos" /><ref>Fitzwater JW, Silva NN, Knight CG, et al. Management of spontaneous pneumomediastinum in children. J Pediatr Surg. 2015 Jun;50(6):983-6. doi: 10.1016/j.jpedsurg.2015.03.024.</ref><ref>Smith BA, Ferguson DB. Disposition of spontaneous pneumomediastinum. Am J Emerg Med. 1991 May;9(3):256-9.</ref>
*Recommend analgesia, rest, and avoidance of actions that increase pulmonary pressure (i.e. Valsalva maneuvers, etc)
 
===Secondary<ref>de Virgilio C, Kim DY. Pneumomediastinum Following Blunt Trauma: Are We Closer to Unlocking Its Significance? JAMA Surg. 2015 Jun 24. doi: 10.1001/jamasurg.2015.1146.</ref>===
*Most cases are benign, but a minority of cases require additional testing and intervention.
*Have lower threshold for additional testing and admission.


==See Also==
==See Also==
*[[Pneumothorax (main)]]
*[[Thoracic Trauma]]
*[[Thoracic Trauma]]
*[[Mediastinitis]]
==External Links==


==Sources==
==References==
Harwood-Nuss, Rosens
<references/>


[[Category:Pulm]]
[[Category:Pulmonary]]

Latest revision as of 14:57, 11 July 2024

Background

The pericardial cavity in this image is labeled d and is part of the inferior mediastium. Here we can see its relation to the superior mediastinum a, the pleural cavities c, and the diaphragm e.
A transverse section of the thorax, showing the contents of the middle and the posterior mediastinum.
  • Also known as mediastinal emphysema
  • Definition: presence of free air in the mediastinum
  • Can be Spontaneous or secondary (to violation of aerodigestive tract)[1]
  • Spontaneous pneumomediastinum usually occurs due to sudden increase in intra-alveolar pressure causing alveolar rupture → air dissects into pulmonary interstitium and then into mediastinum, neck, or pericardium[2]
  • Life threatening causes include esophageal rupture or tension pneumothorax

Etiology[3]

Primary (i.e. Spontaneous)

Secondary

Clinical Features

Differential Diagnosis

Chest pain

Critical

Emergent

Nonemergent

Thoracic Trauma

Evaluation

Pneumomediastinum from nasal insufflation of cocaine.
Traumatic pneumomediastinum and right sided pneumothorax with first rib fracture.
Pneumomediastinum with Angel wing sign
Pneumomediastinum with subcutanous emphysema on CT.
  • CT Chest (preferred diagnostic test)
  • CXR
    • AP/PA - Ring around right pulmonary artery, air along left heart border, air in upper chest/neck soft tissue
    • Lateral - air along anterior heart border
    • Lateral neck - may see mediastinal air in neck
    • 30% with spontaneous pneumomediastinum will have normal CXR[1]

Management

  • Supportive care[4]
    • Pneumomediastinum typically reabsorbs over 1-2 weeks.
  • Treat underlying cause, if identified

Disposition

Primary (Spontaneous)

  • Benign and self-limited disease
  • Generally does not require repeat imaging, and can be managed conservatively on an outpatient basis with follow up in 24 to 48 hours[1][8][9]
  • Recommend analgesia, rest, and avoidance of actions that increase pulmonary pressure (i.e. Valsalva maneuvers, etc)

Secondary[10]

  • Most cases are benign, but a minority of cases require additional testing and intervention.
  • Have lower threshold for additional testing and admission.

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 1.3 Bakhos CT, Pupovac SS, Ata A, et al. Spontaneous pneumomediastinum: an extensive workup is not required. J Am Coll Surg. 2014 Oct;219(4):713-7. doi: 10.1016/j.jamcollsurg.2014.06.001.
  2. ↑ 2.0 2.1 Niehaus M, Rusgo A, Roth K, Jacoby JL. Retropharyngeal air and pneumomediastinum: a rare complication of influenza A and asthma in an adult. Am J Emerg Med. 2015 Jun 14. pii: S0735-6757(15)00495-7. doi: 10.1016/j.ajem.2015.06.020.
  3. ↑ Kouritas VK, et al. Pneumomediastinum. J Thorac Dis. 2015 Feb; 7(Suppl 1): S44–S49. doi: 10.3978/j.issn.2072-1439.2015.01.11
  4. ↑ 4.0 4.1 Johnson JN, Jones R, Wills BK. Spontaneous Pneumomediastinum. Western Journal of Emergency Medicine. 2008;9(4):217-218.
  5. ↑ Quresi SA, Tilyard A (2008). "Unusual Presentation of Spontaneous Mediastinum: A Case Report". Cases Journal 1:349. doi:10.1186/1757-1626-1-349
  6. ↑ Beg MH, Reyazuddin, Ansari MM (1988). "Traumatic tension Pneumomediastinum Mimicking Cardiac Tamponade". Thorax 43:576-677. doi: 10.1136/thx.43.7.576.
  7. ↑ Jennings S, Peeceeyen S, Horton M. Tension pneumomediastinum after blunt chest trauma. ANZ J Surg. 2015 Jan;85(1-2):90-1. doi: 10.1111/ans.12378.
  8. ↑ Fitzwater JW, Silva NN, Knight CG, et al. Management of spontaneous pneumomediastinum in children. J Pediatr Surg. 2015 Jun;50(6):983-6. doi: 10.1016/j.jpedsurg.2015.03.024.
  9. ↑ Smith BA, Ferguson DB. Disposition of spontaneous pneumomediastinum. Am J Emerg Med. 1991 May;9(3):256-9.
  10. ↑ de Virgilio C, Kim DY. Pneumomediastinum Following Blunt Trauma: Are We Closer to Unlocking Its Significance? JAMA Surg. 2015 Jun 24. doi: 10.1001/jamasurg.2015.1146.
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