Pneumomediastinum pathophysiology: Difference between revisions
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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 alveoli and pleural cavity<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>. | *The [[pathophysiology]] of spontaneous pneumomediastinum is based on the existence of a [[Pressure gradient (atmospheric)|pressure gradient]] between the [[Pulmonary alveolus|alveoli]] and [[pleural cavity]]<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, physical activity may lead to alveolar rupture and the consequent escape of air into the 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 interstitium it flows towards the hilum and the mediastinum along a pressure gradient between the | *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, | *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 important precipitating factors of spontaneous pneumomediastinum is the absence of any specific trigger. | *One of the most important precipitating factors 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, ascent phase | *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 of blood or 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 | *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>. | ||
*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. | *[[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, ventilator-induced barotrauma, mediastinitis, foreign body in aerodigestive tract, | *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|PCP]], [[Boerhaave syndrome]], and [[Amiodarone|amiodarone-induced pulmonary toxicity.]] | ||
==Genetics== | ==Genetics== | ||
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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>: | ||
*Broncial asthma | *[[Asthma|Broncial asthma]] | ||
*COPD | *[[Chronic obstructive pulmonary disease|COPD]] | ||
*ARDS | *[[Acute respiratory distress syndrome|ARDS]] | ||
*Boerhaave syndrome | *[[Boerhaave syndrome]] | ||
* | *[[Interstitial lung disease]]: Spontaneous pneumomediastinum is a rare complication of ILD. | ||
*[[Connective tissue disease]]: Spontaneous pneumomediastinum is an uncommon manifestation of CTD<ref name="De GiacomiBaqir2018">{{cite journal|last1=De Giacomi|first1=Federica|last2=Baqir|first2=Misbah|last3=Cox|first3=Christian W.|last4=Moua|first4=Teng|last5=Matteson|first5=Eric L.|last6=Ryu|first6=Jay H.|title=Spontaneous Pneumomediastinum in Connective Tissue Diseases|journal=JCR: Journal of Clinical Rheumatology|year=2018|pages=1|issn=1076-1608|doi=10.1097/RHU.0000000000000835}}</ref>. | |||
*Connective tissue disease: Spontaneous pneumomediastinum is an uncommon manifestation of CTD<ref name="De GiacomiBaqir2018">{{cite journal|last1=De Giacomi|first1=Federica|last2=Baqir|first2=Misbah|last3=Cox|first3=Christian W.|last4=Moua|first4=Teng|last5=Matteson|first5=Eric L.|last6=Ryu|first6=Jay H.|title=Spontaneous Pneumomediastinum in Connective Tissue Diseases|journal=JCR: Journal of Clinical Rheumatology|year=2018|pages=1|issn=1076-1608|doi=10.1097/RHU.0000000000000835}}</ref> | *[[Dermatomyocitis]]: Pneumomediastinum is associated with the complication of vasculopathy appearing as skin lesions in dermatomyocitis<ref name="Kono2000">{{cite journal|last1=Kono|first1=H.|title=Pneumomediastinum in dermatomyositis: association with cutaneous vasculopathy|journal=Annals of the Rheumatic Diseases|volume=59|issue=5|year=2000|pages=372–376|issn=00034967|doi=10.1136/ard.59.5.372}}</ref>. | ||
*[Dermatomyocitis]: Pneumomediastinum is associated with the complication of vasculopathy appearing as skin lesions in | |||
*Tobacco smoking | *Tobacco smoking | ||
*Recreational drug use | *Recreational drug use | ||
| Line 49: | Line 48: | ||
==Microscopic Pathology== | ==Microscopic Pathology== | ||
There are no microscopic histopathological features characteristic for pneumomediastinum. | There are no microscopic [[Histopathology|histopathological]] features characteristic for pneumomediastinum. | ||
==References== | ==References== | ||
Revision as of 16:57, 14 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 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.
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 pleural cavity[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 important precipitating factors 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, PCP, Boerhaave syndrome, and amiodarone-induced pulmonary toxicity.
Genetics
There is no genetic predisposition to pneumomediastinum.
Associated Conditions
Conditions associated with spontaneous pneumomediastinum include[7]:
- Broncial asthma
- COPD
- ARDS
- Boerhaave syndrome
- Interstitial lung disease: Spontaneous pneumomediastinum is a rare complication of ILD.
- Connective tissue disease: Spontaneous pneumomediastinum is an uncommon manifestation of CTD[8].
- Dermatomyocitis: Pneumomediastinum is associated with the complication of vasculopathy appearing as skin lesions in dermatomyocitis[9].
- Tobacco smoking
- Recreational drug use
Gross Pathology
There are no gross pathological findings of 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.