Pneumomediastinum pathophysiology: Difference between revisions
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{{CMG}}; {{AE}} {{Trusha}} | {{CMG}}; {{AE}} {{Trusha}} | ||
==Overview== | ==Overview== | ||
Pneumomediastinum | The [[pathophysiology]] of spontaneous pneumomediastinum is based on the existence of a [[Pressure gradient (atmospheric)|pressure gradient]] between the [[Pulmonary alveolus|alveoli]] and lung interstitium. Pneumomediastinum occurs when pressure rises in the lungs and causes the [[Pulmonary alveolus|air sacs (alveoli)]] to rupture. Sudden increase in intrathoracic pressure due to a specific triggering event such as [[Valsalva maneuver]], vomiting, [[Asthma exacerbation resident survival guide|asthma exacerbation]], physical activity may lead to alveolar rupture and the consequent escape of air into the interstitium. Once the air is in the lung interstitium, it flows towards the [[Hilum of lung|hilum]] and the [[mediastinum]] along a pressure gradient between the [[pleural cavity]] and the [[mediastinum]]. Spontaneous neonatal pneumomediastinum may follow gas trapping associated with the [[Aspiration (medicine)|aspiration]] of blood or [[Meconium aspiration syndrome|meconium]], [[neonatal respiratory distress syndrome]], [[pneumonia]], or the use of [[mechanical ventilation]]. Another possible mechanism is traumatic damage to the [[Lung|lungs]] or other nearby structures that allows air to leak into the center of the chest. | ||
==Pathophysiology== | ==Pathophysiology== | ||
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====Spontaneous pneumomediastinum==== | ====Spontaneous pneumomediastinum==== | ||
*The [[pathophysiology]] of spontaneous pneumomediastinum is based on the existence of a [[Pressure gradient (atmospheric)|pressure gradient]] between the [[Pulmonary alveolus|alveoli]] and | *The [[pathophysiology]] of spontaneous pneumomediastinum is based on the existence of a [[Pressure gradient (atmospheric)|pressure gradient]] between the [[Pulmonary alveolus|alveoli]] and lung interstitium.<ref name="pmid17420139">{{cite journal |vauthors=Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, Perna V, Rivas F |title=Spontaneous pneumomediastinum: 41 cases |journal=Eur J Cardiothorac Surg |volume=31 |issue=6 |pages=1110–4 |date=June 2007 |pmid=17420139 |doi=10.1016/j.ejcts.2007.03.008 |url=}}</ref> | ||
*Sudden increase in intrathoracic pressure due to a specific triggering event such as [[Valsalva maneuver]], vomiting, [[Asthma exacerbation resident survival guide|asthma exacerbation]], physical activity may lead to alveolar rupture and the consequent escape of air into the [[Interstitial|interstitium]]. | *Sudden increase in intrathoracic pressure due to a specific triggering event such as [[Valsalva maneuver]], vomiting, [[Asthma exacerbation resident survival guide|asthma exacerbation]], physical activity may lead to alveolar rupture and the consequent escape of air into the [[Interstitial|interstitium]]. | ||
*Once the air is in the lung [[Interstitial|interstitium]] it flows towards the [[Hilum of lung|hilum]] and the [[mediastinum]] along a pressure gradient between the [[pleural cavity]] and the [[mediastinum]]<ref name="pmid17420139">{{cite journal |vauthors=Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, Perna V, Rivas F |title=Spontaneous pneumomediastinum: 41 cases |journal=Eur J Cardiothorac Surg |volume=31 |issue=6 |pages=1110–4 |date=June 2007 |pmid=17420139 |doi=10.1016/j.ejcts.2007.03.008 |url=}}</ref> | *Once the air is in the lung [[Interstitial|interstitium]] it flows towards the [[Hilum of lung|hilum]] and the [[mediastinum]] along a pressure gradient between the [[pleural cavity]] and the [[mediastinum]].<ref name="pmid17420139">{{cite journal |vauthors=Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, Perna V, Rivas F |title=Spontaneous pneumomediastinum: 41 cases |journal=Eur J Cardiothorac Surg |volume=31 |issue=6 |pages=1110–4 |date=June 2007 |pmid=17420139 |doi=10.1016/j.ejcts.2007.03.008 |url=}}</ref> | ||
*Predisposing factors of spontaneous pneumomediastinum are tobacco smoking, use of recreational drugs, past medical history of [[asthma]], [[pneumonia]], [[Chronic obstructive pulmonary disease|COPD]] and [[interstitial lung disease]]<ref name="DionísioMartins2017">{{cite journal|last1=Dionísio|first1=Patrícia|last2=Martins|first2=Luís|last3=Moreira|first3=Susana|last4=Manique|first4=Alda|last5=Macedo|first5=Rita|last6=Caeiro|first6=Fátima|last7=Boal|first7=Luísa|last8=Bárbara|first8=Cristina|title=Spontaneous pneumomediastinum: experience in 18 patients during the last 12 years|journal=Jornal Brasileiro de Pneumologia|volume=43|issue=2|year=2017|pages=101–105|issn=1806-3756|doi=10.1590/s1806-37562016000000052}}</ref> | *Predisposing factors of spontaneous pneumomediastinum are tobacco smoking, use of recreational drugs, past medical history of [[asthma]], [[pneumonia]], [[Chronic obstructive pulmonary disease|COPD]] and [[interstitial lung disease]].<ref name="DionísioMartins2017">{{cite journal|last1=Dionísio|first1=Patrícia|last2=Martins|first2=Luís|last3=Moreira|first3=Susana|last4=Manique|first4=Alda|last5=Macedo|first5=Rita|last6=Caeiro|first6=Fátima|last7=Boal|first7=Luísa|last8=Bárbara|first8=Cristina|title=Spontaneous pneumomediastinum: experience in 18 patients during the last 12 years|journal=Jornal Brasileiro de Pneumologia|volume=43|issue=2|year=2017|pages=101–105|issn=1806-3756|doi=10.1590/s1806-37562016000000052}}</ref> | ||
*One of the most common scenario of spontaneous pneumomediastinum is the absence of any specific trigger. | *One of the most common scenario of spontaneous pneumomediastinum is the absence of any specific trigger. | ||
*The other precipitating factors are physical exercise, [[vomiting]], [[cough]], [[Upper respiratory tract infection|infection of the upper airways]], inhalation of varnish fumes, rapid ascent or descent phase during dive or [[Hyperbaric medicine|hyperbaric treatment]]<ref name="López-PeláezRoldán2001">{{cite journal|last1=López-Peláez|first1=María F.|last2=Roldán|first2=José|last3=Mateo|first3=Salvador|title=Cervical Emphysema, Pneumomediastinum, and Pneumothorax Following Self-induced Oral Injury|journal=Chest|volume=120|issue=1|year=2001|pages=306–309|issn=00123692|doi=10.1378/chest.120.1.306}}</ref> | *The other precipitating factors are physical exercise, [[vomiting]], [[cough]], [[Upper respiratory tract infection|infection of the upper airways]], inhalation of varnish fumes, rapid ascent or descent phase during dive or [[Hyperbaric medicine|hyperbaric treatment]].<ref name="López-PeláezRoldán2001">{{cite journal|last1=López-Peláez|first1=María F.|last2=Roldán|first2=José|last3=Mateo|first3=Salvador|title=Cervical Emphysema, Pneumomediastinum, and Pneumothorax Following Self-induced Oral Injury|journal=Chest|volume=120|issue=1|year=2001|pages=306–309|issn=00123692|doi=10.1378/chest.120.1.306}}</ref> | ||
=====Spontaneous neonatal pneumomediastinum===== | =====Spontaneous neonatal pneumomediastinum===== | ||
*Spontaneous neonatal pneumomediastinum is associated with the [[Aspiration (medicine)|aspiration]] of blood or [[Meconium aspiration syndrome|meconium]] and birth-related trauma and it is more frequent in post-term newborns<ref name="ZuppaD’Andrea2014">{{cite journal|last1=Zuppa|first1=A. A.|last2=D’Andrea|first2=V.|last3=Verrillo|first3=G.|last4=Riccardi|first4=R.|last5=Savarese|first5=I.|last6=Cavani|first6=M.|last7=Romagnoli|first7=C.|title=Spontaneous neonatal pneumomediastinum: Radiological or clinical diagnosis?|journal=Journal of Obstetrics and Gynaecology|volume=34|issue=2|year=2014|pages=138–140|issn=0144-3615|doi=10.3109/01443615.2013.830597}}</ref> | *Spontaneous neonatal pneumomediastinum is associated with the [[Aspiration (medicine)|aspiration]] of blood or [[Meconium aspiration syndrome|meconium]] and birth-related trauma and it is more frequent in post-term newborns.<ref name="ZuppaD’Andrea2014">{{cite journal|last1=Zuppa|first1=A. A.|last2=D’Andrea|first2=V.|last3=Verrillo|first3=G.|last4=Riccardi|first4=R.|last5=Savarese|first5=I.|last6=Cavani|first6=M.|last7=Romagnoli|first7=C.|title=Spontaneous neonatal pneumomediastinum: Radiological or clinical diagnosis?|journal=Journal of Obstetrics and Gynaecology|volume=34|issue=2|year=2014|pages=138–140|issn=0144-3615|doi=10.3109/01443615.2013.830597}}</ref> | ||
*Spontaneous neonatal pneumomediastinum may follow gas trapping associated with the [[neonatal respiratory distress syndrome]], [[pneumonia]], or the use of [[mechanical ventilation]]<ref name="HackingStewart2001">{{cite journal|last1=Hacking|first1=Doug|last2=Stewart|first2=Michael|title=Neonatal Pneumomediastinum|journal=New England Journal of Medicine|volume=344|issue=24|year=2001|pages=1839–1839|issn=0028-4793|doi=10.1056/NEJM200106143442405}}</ref> | *Spontaneous neonatal pneumomediastinum may follow gas trapping associated with the [[neonatal respiratory distress syndrome]], [[pneumonia]], or the use of [[mechanical ventilation]].<ref name="HackingStewart2001">{{cite journal|last1=Hacking|first1=Doug|last2=Stewart|first2=Michael|title=Neonatal Pneumomediastinum|journal=New England Journal of Medicine|volume=344|issue=24|year=2001|pages=1839–1839|issn=0028-4793|doi=10.1056/NEJM200106143442405}}</ref> | ||
====Secondary pneumomediastinum==== | ====Secondary pneumomediastinum==== | ||
*Secondary pneumomediastinum develops as a consequence of a distinct underlying [[pathology]] or chest/abdominal injury, resulting in the [[Thoracic cavity|intrathoracic]] [[Dissection (medical)|dissection]] of air through the [[Mediastinum|mediastinal planes]]<ref name="CaceresBraud2009">{{cite journal|last1=Caceres|first1=Manuel|last2=Braud|first2=Rebecca L.|last3=Maekawa|first3=Rosalba|last4=Weiman|first4=Darryl S.|last5=Garrett|first5=H. Edward|title=Secondary Pneumomediastinum: A Retrospective Comparative Analysis|journal=Lung|volume=187|issue=5|year=2009|pages=341–346|issn=0341-2040|doi=10.1007/s00408-009-9164-4}}</ref> | *Secondary pneumomediastinum develops as a consequence of a distinct underlying [[pathology]] or chest/abdominal injury, resulting in the [[Thoracic cavity|intrathoracic]] [[Dissection (medical)|dissection]] of air through the [[Mediastinum|mediastinal planes]].<ref name="CaceresBraud2009">{{cite journal|last1=Caceres|first1=Manuel|last2=Braud|first2=Rebecca L.|last3=Maekawa|first3=Rosalba|last4=Weiman|first4=Darryl S.|last5=Garrett|first5=H. Edward|title=Secondary Pneumomediastinum: A Retrospective Comparative Analysis|journal=Lung|volume=187|issue=5|year=2009|pages=341–346|issn=0341-2040|doi=10.1007/s00408-009-9164-4}}</ref> | ||
*[[Iatrogenesis|Iatrogenic]] secondary pneumomediastinum may result from recent interventions in the [[tracheobronchial tree]] or [[Gastrointestinal tract|GI tract]] such as [[Endoscopy|endoscopies]], [[Intubation|intubation/extubation]], surgical intervention such as [[thyroidectomy]], [[tracheostomy]]. | *[[Iatrogenesis|Iatrogenic]] secondary pneumomediastinum may result from recent interventions in the [[tracheobronchial tree]] or [[Gastrointestinal tract|GI tract]] such as [[Endoscopy|endoscopies]], [[Intubation|intubation/extubation]], surgical intervention such as [[thyroidectomy]], [[tracheostomy]]. | ||
*Secondary pneumomediastinum may also result from blunt or penetrating trauma, [[Barotrauma|ventilator-induced barotrauma]], [[mediastinitis]], foreign body in aerodigestive tract, chest cavitary abnormalities, [[pneumocystis jirovecii pneumonia]], [[Boerhaave syndrome]], and [[Amiodarone|amiodarone-induced pulmonary toxicity.]] | *Secondary pneumomediastinum may also result from blunt or penetrating trauma, [[Barotrauma|ventilator-induced barotrauma]], [[mediastinitis]], foreign body in aerodigestive tract, chest cavitary abnormalities, [[pneumocystis jirovecii pneumonia]], [[Boerhaave syndrome]], and [[Amiodarone|amiodarone-induced pulmonary toxicity.]] | ||
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==Associated Conditions== | ==Associated Conditions== | ||
Conditions associated with spontaneous pneumomediastinum include<ref name="Le GoffChérin2008">{{cite journal|last1=Le Goff|first1=Benoit|last2=Chérin|first2=Patrick|last3=Cantagrel|first3=Alain|last4=Gayraud|first4=Martine|last5=Hachulla|first5=Eric|last6=Laborde|first6=Fyriel|last7=Papo|first7=Thomas|last8=Sibilia|first8=Jean|last9=Zabraniecki|first9=Laurent|last10=Ravaud|first10=Philippe|last11=Puéchal|first11=Xavier|title=Pneumomediastinum in interstitial lung disease associated with dermatomyositis and polymyositis|journal=Arthritis Care & Research|volume=61|issue=1|year=2008|pages=108–118|issn=00043591|doi=10.1002/art.24372}}</ref> | Conditions associated with spontaneous pneumomediastinum include:<ref name="Le GoffChérin2008">{{cite journal|last1=Le Goff|first1=Benoit|last2=Chérin|first2=Patrick|last3=Cantagrel|first3=Alain|last4=Gayraud|first4=Martine|last5=Hachulla|first5=Eric|last6=Laborde|first6=Fyriel|last7=Papo|first7=Thomas|last8=Sibilia|first8=Jean|last9=Zabraniecki|first9=Laurent|last10=Ravaud|first10=Philippe|last11=Puéchal|first11=Xavier|title=Pneumomediastinum in interstitial lung disease associated with dermatomyositis and polymyositis|journal=Arthritis Care & Research|volume=61|issue=1|year=2008|pages=108–118|issn=00043591|doi=10.1002/art.24372}}</ref> | ||
*[[Asthma|Broncial asthma]] | *[[Asthma|Broncial asthma]] | ||
Revision as of 17:48, 17 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
The pathophysiology of spontaneous pneumomediastinum is based on the existence of a pressure gradient between the alveoli and lung interstitium. Pneumomediastinum occurs when pressure rises in the lungs and causes the air sacs (alveoli) to rupture. Sudden increase in intrathoracic pressure due to a specific triggering event such as Valsalva maneuver, vomiting, asthma exacerbation, physical activity may lead to alveolar rupture and the consequent escape of air into the interstitium. Once the air is in the lung interstitium, it flows towards the hilum and the mediastinum along a pressure gradient between the pleural cavity and the mediastinum. Spontaneous neonatal pneumomediastinum may follow gas trapping associated with the aspiration of blood or meconium, neonatal respiratory distress syndrome, pneumonia, or the use of mechanical ventilation. Another possible mechanism is traumatic damage to the lungs or other nearby structures that allows air to leak into the center of the chest.
Pathophysiology
Anatomy
For information on anatomy of mediastinum, click here.
Pathogenesis
Spontaneous pneumomediastinum
- The pathophysiology of spontaneous pneumomediastinum is based on the existence of a pressure gradient between the alveoli and lung interstitium.[1]
- Sudden increase in intrathoracic pressure due to a specific triggering event such as Valsalva maneuver, vomiting, asthma exacerbation, physical activity may lead to alveolar rupture and the consequent escape of air into the interstitium.
- Once the air is in the lung interstitium it flows towards the hilum and the mediastinum along a pressure gradient between the pleural cavity and the mediastinum.[1]
- Predisposing factors of spontaneous pneumomediastinum are tobacco smoking, use of recreational drugs, past medical history of asthma, pneumonia, COPD and interstitial lung disease.[2]
- One of the most common scenario of spontaneous pneumomediastinum is the absence of any specific trigger.
- The other precipitating factors are physical exercise, vomiting, cough, infection of the upper airways, inhalation of varnish fumes, rapid ascent or descent phase during dive or hyperbaric treatment.[3]
Spontaneous neonatal pneumomediastinum
- Spontaneous neonatal pneumomediastinum is associated with the aspiration of blood or meconium and birth-related trauma and it is more frequent in post-term newborns.[4]
- Spontaneous neonatal pneumomediastinum may follow gas trapping associated with the neonatal respiratory distress syndrome, pneumonia, or the use of mechanical ventilation.[5]
Secondary pneumomediastinum
- Secondary pneumomediastinum develops as a consequence of a distinct underlying pathology or chest/abdominal injury, resulting in the intrathoracic dissection of air through the mediastinal planes.[6]
- Iatrogenic secondary pneumomediastinum may result from recent interventions in the tracheobronchial tree or GI tract such as endoscopies, intubation/extubation, surgical intervention such as thyroidectomy, tracheostomy.
- Secondary pneumomediastinum may also result from blunt or penetrating trauma, ventilator-induced barotrauma, mediastinitis, foreign body in aerodigestive tract, chest cavitary abnormalities, pneumocystis jirovecii pneumonia, Boerhaave syndrome, and amiodarone-induced pulmonary toxicity.
Genetics
There is no genetics found to be associated with pneumomediastinum.
Associated Conditions
Conditions associated with spontaneous pneumomediastinum include:[7]
- Broncial asthma
- COPD
- ARDS
- Boerhaave syndrome
- Interstitial lung disease (rare)
- Connective tissue disease (rare)[8]
- Dermatomyocitis[9]
- Tobacco smoking
- Recreational drug use
Gross Pathology
There are no gross pathological features characteristic for pneumomediastinum.
Microscopic Pathology
There are no microscopic histopathological features characteristic for pneumomediastinum.
References
- ↑ 1.0 1.1 Macia I, Moya J, Ramos R, Morera R, Escobar I, Saumench J, Perna V, Rivas F (June 2007). "Spontaneous pneumomediastinum: 41 cases". Eur J Cardiothorac Surg. 31 (6): 1110–4. doi:10.1016/j.ejcts.2007.03.008. PMID 17420139.
- ↑ Dionísio, Patrícia; Martins, Luís; Moreira, Susana; Manique, Alda; Macedo, Rita; Caeiro, Fátima; Boal, Luísa; Bárbara, Cristina (2017). "Spontaneous pneumomediastinum: experience in 18 patients during the last 12 years". Jornal Brasileiro de Pneumologia. 43 (2): 101–105. doi:10.1590/s1806-37562016000000052. ISSN 1806-3756.
- ↑ López-Peláez, María F.; Roldán, José; Mateo, Salvador (2001). "Cervical Emphysema, Pneumomediastinum, and Pneumothorax Following Self-induced Oral Injury". Chest. 120 (1): 306–309. doi:10.1378/chest.120.1.306. ISSN 0012-3692.
- ↑ Zuppa, A. A.; D’Andrea, V.; Verrillo, G.; Riccardi, R.; Savarese, I.; Cavani, M.; Romagnoli, C. (2014). "Spontaneous neonatal pneumomediastinum: Radiological or clinical diagnosis?". Journal of Obstetrics and Gynaecology. 34 (2): 138–140. doi:10.3109/01443615.2013.830597. ISSN 0144-3615.
- ↑ Hacking, Doug; Stewart, Michael (2001). "Neonatal Pneumomediastinum". New England Journal of Medicine. 344 (24): 1839–1839. doi:10.1056/NEJM200106143442405. ISSN 0028-4793.
- ↑ Caceres, Manuel; Braud, Rebecca L.; Maekawa, Rosalba; Weiman, Darryl S.; Garrett, H. Edward (2009). "Secondary Pneumomediastinum: A Retrospective Comparative Analysis". Lung. 187 (5): 341–346. doi:10.1007/s00408-009-9164-4. ISSN 0341-2040.
- ↑ Le Goff, Benoit; Chérin, Patrick; Cantagrel, Alain; Gayraud, Martine; Hachulla, Eric; Laborde, Fyriel; Papo, Thomas; Sibilia, Jean; Zabraniecki, Laurent; Ravaud, Philippe; Puéchal, Xavier (2008). "Pneumomediastinum in interstitial lung disease associated with dermatomyositis and polymyositis". Arthritis Care & Research. 61 (1): 108–118. doi:10.1002/art.24372. ISSN 0004-3591.
- ↑ De Giacomi, Federica; Baqir, Misbah; Cox, Christian W.; Moua, Teng; Matteson, Eric L.; Ryu, Jay H. (2018). "Spontaneous Pneumomediastinum in Connective Tissue Diseases". JCR: Journal of Clinical Rheumatology: 1. doi:10.1097/RHU.0000000000000835. ISSN 1076-1608.
- ↑ Kono, H. (2000). "Pneumomediastinum in dermatomyositis: association with cutaneous vasculopathy". Annals of the Rheumatic Diseases. 59 (5): 372–376. doi:10.1136/ard.59.5.372. ISSN 0003-4967.