Pneumomediastinum: Difference between revisions
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==Background== | ==Background== | ||
[[File: | [[File:Gray968.png|thumb|A transverse section of the thorax, showing the contents of the middle and the posterior mediastinum.]] | ||
*Also known as mediastinal emphysema | *Also known as mediastinal emphysema | ||
*Definition: presence of free air in the mediastinum | *Definition: presence of free air in the mediastinum | ||
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*Life threatening causes include [[esophageal rupture]] or [[tension pneumothorax]] | *Life threatening causes include [[esophageal rupture]] or [[tension pneumothorax]] | ||
===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>=== | |||
====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> | |||
=== | ====Secondary==== | ||
* | *Intrinsic Lung and Airway | ||
**[[Asthma]]/[[COPD]] ( | **[[Asthma]] / [[COPD]] (most common co-morbidity<ref name="Bakhos" />) | ||
** | **Bronchiectasis | ||
** | **Interstitial lung disease | ||
**Influenza A<ref name="Niehaus" /> | **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]]) | **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) | **Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest) | ||
**[[ | **[[Childbirth]] | ||
==Clinical Features== | ==Clinical Features== | ||
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*[[Dyspnea]] | *[[Dyspnea]] | ||
*[[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> | ||
*Voice change, cough, stridor | *Voice change, [[cough]], [[stridor]] | ||
*"Crunching" sound on auscultation during systole (Hamman's crunch) | *"Crunching" sound on auscultation during systole (Hamman's crunch) | ||
*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> | *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> | ||
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{{Thoracic trauma DDX}} | {{Thoracic trauma DDX}} | ||
== | ==Evaluation== | ||
[[File:PMC3047855 12245 2010 205 Fig1 HTML.png|thumb|Pneumomediastinum from nasal insufflation of cocaine.]] | |||
[[File:PneumoMediastinum2008.jpg|thumb|Traumatic pneumomediastinum and right sided pneumothorax with first rib fracture.]] | [[File:PneumoMediastinum2008.jpg|thumb|Traumatic pneumomediastinum and right sided pneumothorax with first rib fracture.]] | ||
[[File:Pneumomediastinum-003.jpg|thumb|Pneumomediastinum with Angel wing sign]] | [[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) | *CT Chest (preferred diagnostic test) | ||
*[[CXR]] | *[[CXR]] | ||
**AP/PA - Ring around right pulmonary artery, air along | **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 - air along anterior heart border | ||
**Lateral neck - may see mediastinal air in neck | |||
**30% with spontaneous pneumomediastinum will have normal CXR<ref name="Bakhos" /> | **30% with spontaneous pneumomediastinum will have normal CXR<ref name="Bakhos" /> | ||
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==Disposition== | ==Disposition== | ||
===Primary (Spontaneous)=== | |||
*Benign and self-limited disease | |||
*Generally does not require repeat imaging, and can be managed conservatively on an outpatient basis<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> | |||
===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== | ||
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<references/> | <references/> | ||
[[Category: | [[Category:Pulmonary]] | ||
Revision as of 12:28, 10 April 2021
Background
- 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)
- No identified cause
- Smoking or tobacco use
- Recreational drug inhalation (cocaine, methamphetamine, marijuana)[4]
Secondary
- Intrinsic Lung and Airway
- Asthma / COPD (most common co-morbidity[1])
- Bronchiectasis
- Interstitial lung disease
- Lung cancer
- Foreign body in the airway
- Mycoplasma pneumoniae pneumonia
- Influenza A[2]
- 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, flight)
- Other
- Excessive vomiting (i.e., Boerhaave syndrome, anorexia nervosa)
- Esophageal rupture (rare)
- Hydrocarbon inhalation
- Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest)
- Childbirth
Clinical Features
- Chest pain
- Dyspnea
- Subcutaneous emphysema, especially of face, neck, and chest.[5]
- Voice change, cough, stridor
- "Crunching" sound on auscultation during systole (Hamman's crunch)
- Severe cases (generally after trauma) may mimic cardiac tamponade[6][7]
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
Evaluation
- 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[1][8][9]
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
- ↑ 1.0 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.
- ↑ 2.0 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.
- ↑ 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
- ↑ 4.0 4.1 Johnson JN, Jones R, Wills BK. Spontaneous Pneumomediastinum. Western Journal of Emergency Medicine. 2008;9(4):217-218.
- ↑ Quresi SA, Tilyard A (2008). "Unusual Presentation of Spontaneous Mediastinum: A Case Report". Cases Journal 1:349. doi:10.1186/1757-1626-1-349
- ↑ Beg MH, Reyazuddin, Ansari MM (1988). "Traumatic tension Pneumomediastinum Mimicking Cardiac Tamponade". Thorax 43:576-677. doi: 10.1136/thx.43.7.576.
- ↑ 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.
- ↑ 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.
- ↑ Smith BA, Ferguson DB. Disposition of spontaneous pneumomediastinum. Am J Emerg Med. 1991 May;9(3):256-9.
- ↑ 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.