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 | *Also known as mediastinal emphysema | ||
*Life threatening cause is [[ | *Definition: air present in the mediastinum | ||
*If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is | **Usually occurs with sudden increase in intra-alveolar pressure causing alveolar rupture, air dissects into pulmonary interstitium and then into mediastinum, neck, or pericardium | ||
*Life threatening cause is [[esophageal rupture]] | |||
*If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is not a life threatening condition | |||
===Causes=== | ===Causes=== | ||
*Illegal drug use | *Illegal drug use | ||
**Inhaling cocaine | |||
**Smoking cocaine | |||
**Smoking marijuana | |||
*Vomiting | *Vomiting | ||
*Retching | *Retching | ||
*Coughing | *Coughing | ||
*Asthma | *[[Asthma]]/[[COPD]] | ||
*Esophageal rupture | *Esophageal rupture | ||
* | *[[Thoracic trauma]] | ||
**Search for other more serious injuries (larynx, bronchus, esophagus) | **Search for other more serious injuries (larynx, bronchus, esophagus) | ||
*Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest) | *Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest) | ||
*[[Mycoplasma pneumoniae]] [[pneumonia]] | *[[Mycoplasma pneumoniae]] [[pneumonia]] | ||
*Environmental [[barotrauma]] (e.g. [[Scuba diving emergencies|scuba diving]], [[Commercial in-flight medical emergencies|flight]]) | *Environmental [[barotrauma]] (e.g. [[Scuba diving emergencies|scuba diving]], [[Commercial in-flight medical emergencies|flight]]) | ||
*Iatrogenic (e.g. during thoroscopy/VATS) | *Iatrogenic (e.g. during thoroscopy/VATS) or endoscopy | ||
==Clinical Features== | ==Clinical Features== | ||
*[[Chest pain]] | *[[Chest pain]] | ||
*[[Dyspnea]] | *[[Dyspnea]] | ||
*Voice | *Voice change, cough, stridor | ||
*[[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> | *[[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> | ||
*"Crunching" sound on auscultation | *"Crunching" sound on auscultation during systole (Hamman's crunch) | ||
*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> | *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> | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Template:Chest Pain DDX}} | |||
{{Thoracic trauma DDX}} | |||
==Diagnosis== | ==Diagnosis== | ||
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[[File:Pneumomediastinum-003.jpg|thumb|Pneumomediastinum with Angel wing sign]] | [[File:Pneumomediastinum-003.jpg|thumb|Pneumomediastinum with Angel wing sign]] | ||
*[[CXR]] or chest CT | *[[CXR]] or chest CT | ||
** | **AP/PA - Ring around right pulmonary artery, air along L heart border, air in upper chest/neck soft tissue | ||
**Lateral - air along anterior heart border | |||
*Rule-out esophageal rupture by hx and exam or with esophagoscopy if indicated | |||
==Management== | ==Management== | ||
* | *Supportive | ||
**No specific therapy for spontaneous pneumomediastinum | |||
*Treat underlying cause | |||
==Disposition== | ==Disposition== | ||
*Depends on underlying cause and severity of condition | |||
*Most pts with spontaneous pneumomediastinum, not caused by trauma or esophageal rupture, can be safely discharged | |||
==See Also== | ==See Also== | ||
*[[Pneumothorax (main)]] | *[[Pneumothorax (main)]] | ||
*[[Thoracic Trauma]] | |||
*[[Mediastinitis]] | |||
==External Links== | ==External Links== | ||
Revision as of 23:46, 13 May 2015
Background
- Also known as mediastinal emphysema
- Definition: air present in the mediastinum
- Usually occurs with sudden increase in intra-alveolar pressure causing alveolar rupture, air dissects into pulmonary interstitium and then into mediastinum, neck, or pericardium
- Life threatening cause is esophageal rupture
- If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is not a life threatening condition
Causes
- Illegal drug use
- Inhaling cocaine
- Smoking cocaine
- Smoking marijuana
- Vomiting
- Retching
- Coughing
- Asthma/COPD
- Esophageal rupture
- Thoracic trauma
- Search for other more serious injuries (larynx, bronchus, esophagus)
- Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest)
- Mycoplasma pneumoniae pneumonia
- Environmental barotrauma (e.g. scuba diving, flight)
- Iatrogenic (e.g. during thoroscopy/VATS) or endoscopy
Clinical Features
- Chest pain
- Dyspnea
- Voice change, cough, stridor
- Subcutaneous emphysema, especially of face, neck, and chest.[1]
- "Crunching" sound on auscultation during systole (Hamman's crunch)
- May mimic cardiac tamponade[2]
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Diagnosis
- CXR or chest CT
- AP/PA - Ring around right pulmonary artery, air along L heart border, air in upper chest/neck soft tissue
- Lateral - air along anterior heart border
- Rule-out esophageal rupture by hx and exam or with esophagoscopy if indicated
Management
- Supportive
- No specific therapy for spontaneous pneumomediastinum
- Treat underlying cause
Disposition
- Depends on underlying cause and severity of condition
- Most pts with spontaneous pneumomediastinum, not caused by trauma or esophageal rupture, can be safely discharged