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=== Physical Examination ===
=== Physical Examination ===
In spontaneous pneumomediastinum, the patient appears normal. Patient with pneumomediastinum secondary to an [[Asthma exacerbation resident survival guide|exacerbation of asthma]] may appear [[Distress|distressed.]] On physical examination, the most [[pathognomic sign]] of pneumomediastinum is [[Hamman's sign]], which is [[Mediastinum|mediastinal]] crunch or click present on [[auscultation]] over the [[Apex of the heart|cardiac apex]] and the [[left sternal border]] synchronous with the heartbeat. [[Subcutaneous emphysema]] can also be detected in a patient with pneumomediastinum.
In spontaneous pneumomediastinum, the patient appears normal. Patient with pneumomediastinum secondary to an [[Asthma exacerbation resident survival guide|exacerbation of asthma]] may appear [[Distress|distressed.]] On physical examination, the most [[pathognomic sign]] of pneumomediastinum is [[Hamman's sign [[Mediastinum|mediastinal]] crunch or click present on [[auscultation]] over the [[Apex of the heart|cardiac apex]] and the [[left sternal border]] synchronous with the heartbeat. [[Subcutaneous emphysema]] can also be detected in a patient with pneumomediastinum.


=== Laboratory Findings ===
=== Laboratory Findings ===
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===Imaging Findings===
===Imaging Findings===
[[Computed tomography|CT scan]] of chest is the imaging modality of choice for pneumomediastinum. On [[Radiology|radiological]] investigations such as [[Computed tomography|CT scan]] or [[X-rays|X-ray]] of chest, pneumomediastinum is characterized by the presence of gas in the [[Subcutaneous tissue|subcutaneous tissues]] and [[Mediastinum|mediastinum.]]
[[Computed tomography|CT scan]] of chest is the imaging modality of choice for pneumomediastinum. On [[Radiology|radiological]] investigations such as [[Computed tomography|CT scan]] or [[X-rays|X-ray]] of chest, pneumomediastinum is characterized by free air in the [[Subcutaneous tissue|subcutaneous tissues]] and [[Mediastinum|mediastinum.]]


=== Other Diagnostic Studies ===
=== Other Diagnostic Studies ===

Revision as of 16:55, 15 December 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Trusha Tank, M.D.[2]

Overview

Pneumomediastinum (from Greek pneuma - "air", also known as mediastinal emphysema) is a condition in which air is present in the mediastinum.

The condition can result from physical trauma or other situations that lead to high pressure within the alveoli of the lung, causing them to burst and leak air into the chest cavity.

Historical Perspective

The condition was first described in 1819 by René Laennec.

Classification

Pneumomediastinum is classified according to cause into spontaneous pneumomediastinum and secondary pneumomediastinum. Both the categories are further classified according to their causes. Pneumomediastinum can also be classified according to the entry of air into the mediastinal cavity: Head/neck/upper respiratory tract, lower respiratory tract, gastrointestinal tract, or external sources.

Pathophysiology

Pneumomediastinum can happen when pressure rises in the lungs and causes the air sacs (alveoli) to rupture. Another possible cause is damage to the lungs or other nearby structures that allow air to leak into the center of the chest.

Causes

Spontaneous pneumomediastinum may be caused without any underlying pathology. Secondary pneumomediastinum may be caused by blunt or penetrating trauma to the neck, chest or abdomen. Iatrogenic causes include disruption of the airways or GI tract during endoscopic procedures, intubation/extubation, central vascular access procedure, pleural cavity instrumentation, chest or abdominal surgery. Pneumomediastinum has also been associated with: Mycoplasma pneumonia, anorexia, obesity and pulmonary barotrauma in scuba diver, or an airplane passenger during rapid ascends or descends.

Differentiating [disease name] from other Diseases

  • [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:
  • [Differential dx1]
  • [Differential dx2]
  • [Differential dx3]

Epidemiology and Demographics

Pneumomediastinum is a rare condition. Epidemiology of pneumomediastinum reflects the epidemiology of diseases associated with the condition. Spontaneous pneumomediastinum is more common in young men and pregnant women. Infants have high incidence rates of pneumomediastinum.

Risk Factors

Factors that can increase the chances of pneumomediastinum include age: Infants and young adults are at high risk. Gender: Males have a higher incident rate than females. A tall, lean, male body habitus is considered a risk factor for pneumomediastinum. Preexisting pulmonary disease: People with lung diseases such as asthma, bronchiectasis, cystic fibrosis, COPD, interstitial lung disease, and cysts, are at higher risk of the pneumomediastinum.

Natural History, Complications and Prognosis

Pneumomediastinum is considered a benign entity with good prognosis. The main symptom of pneumomediastinum is chest pain. The onset of the pain is sudden and acute or follows exacerbations of underlying pathology such as asthma. Spontaneous pneumomediastinum usually resolves by itself, but prolonged cases have also been reported (>2 months). There also have been incidences of recurrence.

Diagnosis

Diagnostic Criteria

There are no specific criteria associated with diagnosis of pneumomediastinum.

Symptoms

The clinical presentation of pneumomediastinum depends on the causative or precipitating factor such as exacerbation of asthma, Boerhaave syndrome or pneumonia. Common symptoms of pneumomediastinum include severe, acute pain in the chest(pain may radiate to the shoulders or back), fever, subcutaneous emphysema, shortness of breath, neck pain, jaw pain, dysphonia, dysphagia, emesis or swelling of neck, face, chest, abdomen or shoulder.

Physical Examination

In spontaneous pneumomediastinum, the patient appears normal. Patient with pneumomediastinum secondary to an exacerbation of asthma may appear distressed. On physical examination, the most pathognomic sign of pneumomediastinum is [[Hamman's sign mediastinal crunch or click present on auscultation over the cardiac apex and the left sternal border synchronous with the heartbeat. Subcutaneous emphysema can also be detected in a patient with pneumomediastinum.

Laboratory Findings

There are no specific laboratory findings associated with pneumomediastinum.

Imaging Findings

CT scan of chest is the imaging modality of choice for pneumomediastinum. On radiological investigations such as CT scan or X-ray of chest, pneumomediastinum is characterized by free air in the subcutaneous tissues and mediastinum.

Other Diagnostic Studies

There are no other diagnostic studies associated with pneumomediastinum.

Treatment

Medical Therapy

Pneumomediastinum is considered a benign condition. The first step in the treatment is the exclusion of any significant pathology causing pneumomediastinum and if diagnosed, treat the underlying conditions. In case of spontaneous pneumomediastinum without any complications, patients are required to be hospitalized for 24 hours for observational purposes.

Surgery

Pneumomediastinum is considered a benign condition and does not require surgical intervention in uncomplicated cases. Surgical treatment varies from minor skin incision or chest tube drainage to major VATS (Video-assisted thoracoscopic surgery) or thoracotomy depending on the amount and location of air present in the mediastinum.

Prevention

The primary mode of prevention in case of pneumomediastinum is to prevent and avoid precipitating factors. Children should be completely vaccinated, medical conditions associated with pneumomediastinum should be treated aggressively. All the medical or surgical procedures that can damage the tracheobronchial tree or gastrointestinal tract should be performed under ultrasound guidance.

References


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