Pneumomediastinum: Difference between revisions
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*Also known as mediastinal emphysema | *Also known as mediastinal emphysema | ||
*Definition: air present in the mediastinum | *Definition: air present in the mediastinum | ||
*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 | *Life threatening causes include [[esophageal rupture]] or [[tension pneumothorax]] | ||
*If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is not a life threatening condition | *If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is not a life threatening condition | ||
===Causes=== | ===Causes=== | ||
* | *Recreational drug use (via 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> | ||
*Hydrocarbon inhalation | |||
*[[Asthma]]/[[COPD]] (Spontaneous or secondary to forceful coughing in the setting of bronchospasm) | |||
*Influenza A<ref name="Niehaus" /> | |||
* | *[[Esophageal rupture]] | ||
*[[Asthma]]/[[COPD]] | |||
*Esophageal rupture | |||
*[[Thoracic trauma]] | *[[Thoracic trauma]] | ||
*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 [[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]]) | ||
*Iatrogenic | *Iatrogenic - e.g. thoroscopy, VATS, bronchoscopy, colonoscopy or endoscopy | ||
*Blast injury | |||
==Clinical Features== | ==Clinical Features== | ||
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[[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]] | ||
*[[CXR]] | *[[CXR]] | ||
**AP/PA - Ring around right pulmonary artery, air along L heart border, air in upper chest/neck soft tissue | **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 | **Lateral - air along anterior heart border | ||
* | *CT Chest | ||
==Management== | ==Management== | ||
*Supportive | *Supportive care<ref name="Johnson" /> | ||
** | **Pneumomediastinum typically reabsorbs over 1-2 weeks. | ||
*Treat underlying cause, if identified | |||
*Treat underlying cause | |||
==Disposition== | ==Disposition== | ||
*Depends on underlying cause and severity of condition | *Depends on underlying cause and severity of condition | ||
*Most patients with spontaneous pneumomediastinum | *Most patients with spontaneous pneumomediastinum without trauma or life-threatening condition (e.g. esophageal rupture or tension pneumothorax) can be safely discharged | ||
==See Also== | ==See Also== | ||
Revision as of 05:17, 22 July 2015
Background
- Also known as mediastinal emphysema
- Definition: air present in the mediastinum
- 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[1]
- Life threatening causes include esophageal rupture or tension pneumothorax
- If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is not a life threatening condition
Causes
- Recreational drug use (via inhalation) - cocaine, methamphetamine, marijuana[2]
- Hydrocarbon inhalation
- Asthma/COPD (Spontaneous or secondary to forceful coughing in the setting of bronchospasm)
- Influenza A[1]
- Esophageal rupture
- Thoracic trauma
- Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest)
- Mycoplasma pneumoniae pneumonia
- Environmental pulmonary barotrauma (e.g. scuba diving, flight)
- Iatrogenic - e.g. thoroscopy, VATS, bronchoscopy, colonoscopy or endoscopy
- Blast injury
Clinical Features
- Chest pain
- Dyspnea
- Voice change, cough, stridor
- Subcutaneous emphysema, especially of face, neck, and chest.[3]
- "Crunching" sound on auscultation during systole (Hamman's crunch)
- May mimic cardiac tamponade[4]
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
- 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
- CT Chest
Management
- Supportive care[2]
- Pneumomediastinum typically reabsorbs over 1-2 weeks.
- Treat underlying cause, if identified
Disposition
- Depends on underlying cause and severity of condition
- Most patients with spontaneous pneumomediastinum without trauma or life-threatening condition (e.g. esophageal rupture or tension pneumothorax) can be safely discharged
See Also
External Links
References
- ↑ 1.0 1.1 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.
- ↑ 2.0 2.1 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.