Pneumomediastinum: Difference between revisions
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==Background== | ==Background== | ||
[[File:Subcutaneous emphysema chest cropped.jpg|thumb]] | [[File:Subcutaneous emphysema chest cropped.jpg|thumb|Pneumomediastinum with subcutanous emphysema on CT.]] | ||
*Also known as mediastinal emphysema | *Also known as mediastinal emphysema | ||
*Definition: air present in the mediastinum | *Definition: air present in the mediastinum | ||
Revision as of 23:49, 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 patients with spontaneous pneumomediastinum, not caused by trauma or esophageal rupture, can be safely discharged