Clinical experience of spontaneous pneumomediastinum: diagnosis and treatment

Spontaneous pneumomediastinum: A comprehensive review of diagnosis and management

Pneumomediastinum is a rare condition defined by the presence of air in the mediastinum. In the absence of traumatic injury, iatrogenic injury, or clear etiology, it is called spontaneous pneumomediastinum (SPM). Spontaneous pneumomediastinum most commonly occurs in younger individuals and has a self-limiting course with a good outcome. The purpose of the present manuscript is to systematically review the existing literature on SPM evaluation and management for updated clinical understanding of this condition. A literature search was conducted of publications about SPM on MEDLINE/PubMed and Google Scholar by identifying all the articles with key search terms "pneumomediastinum" and "spontaneous pneumomediastinum". Inclusion criteria were case series published in English between 1980 and 2023. In total, 24 case series were selected and reviewed to determine presenting symptoms, clinical signs and predisposing factors associated with spontaneous pneumomediastinum. Most patients were male; the average age at diagnosis was 26.3 years. The most common presenting symptoms were chest pain and dyspnea. The most common exam finding was subcutaneous emphysema, in 35.4% of patients. Only 5.9% had the classic Hamman's sign. Risk factors include history of asthma, history of smoking, and recent physical activity. This manuscript presents an extensive review of relevant literature highlighting the diagnosis and essential management of spontaneous pneumomediastinum.

Short-term changes in chest CT images among individuals at low altitude after entering high-altitude environments

Objective

To investigate the short-term changes in chest CT images of low-altitude populations after entering a high-altitude environment.

Methods

Chest CT images of 3,587 people from low-altitude areas were obtained within one month of entering a high-altitude environment. Abnormal CT features and clinical symptoms were analyzed.

Results

Besides acute high-altitude pulmonary edema, the incidence of soft tissue space pneumatosis was significantly higher than that in low-altitude areas. Pneumatosis was observed in the mediastinum, cervical muscle space, abdominal cavity, and spinal cord epidural space, especially the mediastinum.

Conclusion

In addition to acute high-altitude pulmonary edema, spontaneous mediastinal emphysema often occurs when individuals in low-altitude areas adapt to the high-altitude environment of cold, low-pressure, and hypoxia. When the gas escapes to the abdominal cavity, it is easy to be misdiagnosed as gastrointestinal perforation. It is also not uncommon for gas accumulation to escape into the epidural space of the spinal cord. The phenomenon of gas diffusion into distant tissue space and the mechanism of gas escape needs to be further studied.

A clinical review of spontaneous pneumomediastinum

Primary spontaneous pneumomediastinum is a rare, often benign and self-limited condition defined by air within the mediastinum. However, correctly distinguishing primary spontaneous pneumomediastinum from secondary causes, especially esophageal perforation, remains a diagnostic challenge. There is significant debate regarding the balance of completing a thorough but not overly invasive and costly diagnostic workup. This clinical review aims to gather the limited data regarding spontaneous pneumomediastinum management from case series and retrospective cohort studies, and presents an evaluation algorithm and treatment plan stratified by clinical history. Understanding specifically if the patient presents with coughing versus forceful vomiting is critical to help elucidate the etiology and guide management of pneumomediastinum. Patients who present with forceful vomiting or retching should be considered with higher degree of suspicion for secondary causes of pneumomediastinum, specifically esophageal perforation. However, especially in children, aggressive diagnostic workup is not warranted in every case. After ruling out other etiologies of pneumomediastinum, spontaneous pneumomediastinum can be commonly treated with symptomatic management without the aggressive use of antibiotics or diet restriction. Hospital length of stay may also be minimized on a case-by-case basis. Overall, recurrence of spontaneous pneumomediastinum is rare and outpatient follow up may be safely limited to those at highest risk of recurrence.

Spontaneous Pneumomediastinum Resulting From Passionate Cheering at a Soccer Match

Spontaneous pneumomediastinum is a rare and self-limiting clinical entity, often triggered by activities causing acute changes in intrathoracic pressure such as childbirth, strenuous exercise, vomiting, and coughing. We present a case of a young male soldier who developed spontaneous pneumothorax following persistent yelling while attending a soccer match. Spontaneous pneumomediastinum may be preceded by a variety of strenuous activities, and clinicians should be aware of this entity when performing the evaluation of patients with nonspecific symptoms such as chest pain and dyspnea. Patients diagnosed with pneumomediastinum but presenting with additional findings such as vomiting and pleural effusion should be thoroughly evaluated to rule out potentially life-threatening mediastinal organ injury. Return to military duty should be determined by clinical reevaluation and follow-up imaging findings.

Oxygen Therapy Part 2 - Indications and Toxicity

Oxygen Therapy Part 2: Indications and ToxicityWemple et al. continue their review of oxygen therapy, discussing the acute and chronic indications for oxygen and the delivery of supplemental oxygen (and its potential adverse effects and toxicity).

Rare complications of anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis: Time to nip them in the bud

Anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis (MDA5+ DM) is an infrequent autoimmune disease, which mainly distributes in Asians and females. MDA5+ DM usually presents various skin lesions and positive anti-MDA5 antibody (a myositis-specific autoantibody for itself) with amyopathic or hypomyopathic features. For MDA5+ DM patients, rapidly progressive interstitial lung disease is a common complication with a high-speed deterioration and a poor prognosis. Besides, there are other complications of MDA5+ DM patients, including pneumomediastinum, macrophage activation syndrome and spontaneous intramuscular hemorrhage. These complications were rare but lethal, so it is necessary to explore their diagnosis methods, therapies and potential mechanisms, which are helpful for early diagnoses and timely treatment. To date, several cases and studies have shown distinctive features, diagnoses and treatments of these three rare complications, and there are also some differences among them. In this review, we outlined the characteristics, administration and potential pathogenesis of these rare complications of MDA5+ DM.

Pneumorrhachis: An uncommon radiological entity

Pneumorrhachis (PR) is a rare and interesting phenomenon, in which air is present within the spinal canal. The aetiologies are varied, broadly grouped as traumatic, non-traumatic or iatrogenic. Pneumorrhachis secondary to spontaneous pneumomediastinum (SPM) and barotrauma of the lungs is uncommon and even rarer within the paediatric group. This report describes a paediatric patient presenting with a persistent cough who developed a SPM and subsequent PR.

Spontaneous Pneumomediastinum in a Healthy Pediatric Patient

Spontaneous pneumomediastinum (SPM) is a rare condition, especially in children with no predisposing factors. In the vast majority of patients, this condition is benign and self-limiting; however, there is always the possibility that serious and potentially life-threatening complications such as mediastinitis or cardiac tamponade could arise. Early recognition, prompt diagnosis, and appropriate management allow for ideal care and prevent unnecessary and excessive investigations in these patients. An eight-year-old female was admitted to the emergency department with SPM after swimming and no known predisposing lung conditions. The probable causative event was likely to be pressure changes in the alveoli during swimming. This is notable because the patient's SPM occurred in the absence of an underlying cause such as asthma. The patient was admitted overnight for monitoring and pain control. The symptoms resolved the following day, along with a decrease in the size of the SPM on the chest X-ray. Physicians should be aware of the signs of SPM in young patients who present with chest pain in the absence of trauma or pulmonic disease. A review of literature highlighted the pathophysiology and recommended treatment course for similar cases.

Pneumomediastinum and pneumopericardium 11 days after Whipple procedure. A case report and review if the literature

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Spontaneous Pneumomediastinum is a rare disease.

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Combination with Pneumopericardium has not been reported yet.

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There are no clear guidelines for diagnosis and treatment.

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Conservative treatment with close monitoring is most of the times sufficient.

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In surgical patients an upgraded diagnostic and treatment plan could be necessary.

Introduction

Spontaneous pneumomediastinum (SPM) is a rare condition classified as free air in the mediastinum in the absence of any precipitating cause. This is the first time that a synchronous presence of pneumopericardium is described. To date, there are no clear guidelines for diagnosis and treatment.

Presentation of a case

A 34-year old Caucasian male patient presented to our institution with a recently diagnosed pancreatic adenocarcinoma. He underwent an uneventful pancreaticoduodenectomy (Whipple procedure). Preoperative and intraoperative chest X-Ray after a central line placement were normal. The postoperative course was uneventful, but few hours before his discharge he presented an acute tachycardia and tachypnea with hypocapnia and a transient loss of consciousness. The full-body CT scan revealed a pneumomediastinum and pneumopericardium without any findings of anastomotic leak or other pathology from the abdomen. A meticulous review of the literature was conducted about the pathophysiology, treatment options and outcomes of pneumomediastinum after a surgical procedure.

Discussion

This is the first study presenting the case of spontaneous pneumomediastinum with a synchronous pneumopericardium in the literature as a late complication of Whipple procedure. The applied diagnostic algorithm and conservative treatment are presented to extend our limited knowledge about this rare medical entity.

Conclusion

Awareness of these medical entities is important for the adequate management and optimal outcome of patients presenting a spontaneous pneumomediastinum. As such, all cases, treatment decisions and outcomes should be reported.

Spontaneous Pneumomediastinum and Diffuse Subcutaneous Emphysema after Methamphetamine Inhalation

Methamphetamines are commonly abused drugs for their stimulant and euphoric effects. Inhaled and intravenous use may cause damage to the respiratory system. Spontaneous pneumomediastinum is a condition where changes in intrathoracic pressure leads to alveolar rupture and dissection of air along the tracheobronchial tree. Massive subcutaneous emphysema may result from pneumomediastinum which may compromise the central airway. In this case report, we present an unusual case of spontaneous pneumomediastinum and severe subcutaneous emphysema following inhalation of methamphetamine. This case emphasizes the rising concern on the acute respiratory complications of methamphetamine use.

Cocaine-Induced Pneumopericardium: Safe for Discharge? A Case Report and Literature Review

A 29-year-old male presented at the Emergency Department (ED) with chest pain and neck tenderness after intranasal cocaine usage. Physical exam of the patient demonstrated moderate subcutaneous emphysema on the right side of his neck. The ECG did not demonstrate any changes associated with cocaine-induced cardiac ischemia, and blood analysis was normal (negative troponins). A chest X-ray revealed subtle evidence of pneumomediastinum. Subsequent thoracic CT confirmed the presence of subcutaneous emphysema with a pneumopericardium and a large pneumomediastinum along with a small pneumothorax. The patient was managed conservatively and kept overnight for observation. He was discharged from the ED the following day with ambulatory follow-up. A repeat thoracic CT performed two weeks later demonstrated that the findings identified in the first CT had resolved. Pneumopericardium, -mediastinum, and -thorax are rare conditions reported after cocaine abuse. A conservative approach with a period of observation in a suitable ambulatory unit is acceptable, as current literature suggests that the condition is usually self-limiting.

An unexpected complication of robotic cardiac surgery: Pneumomediastinum

Pneumomediastinum is a rare entity that is defined as free air in the mediastinal space. A 26-year-old male patient was admitted with pneumomediastinum as an unexpected complication of robotic surgery. Diffuse subcutanous emphysema was observed suddenly on Postoperative Day 3 without respiratory distress. Air trapping into the mediastinum was seen on chest X-ray and computed tomography. The patient was followed in the intensive care unit for 7 days and managed conservatively. Subcutaneous emphysema reduced gradually. In conclusion, although it is a rare condition, pneumomediastinum should be kept in mind as a complication of robotic cardiac surgery.

Hamman's syndrome (spontaneous pneumomediastinum presenting as subcutaneous emphysema): A rare case of the emergency department and review of the literature

Pneumomediastinum is a rare clinical entity that concerns the clinicians in the emergency department. We present a case of a patient with spontaneous pneumomediastinum (Hamman's syndrome) that presented to our hospital's emergency department with cervical subcutaneous emphysema. A conservative treatment with observation was performed. The patient after 24 hours of observation was discharged with a suggested follow-up.

Spontaneous pneumomediastinum complicating severe acute asthma exacerbation in adult patients

Objectives: The real incidence of pneumomediastinum (PNM) in adult patients with severe acute asthma exacerbation continues to be unknown. The current study aims to investigate the occurrence of PNM in an adult population of patients presenting a severe asthma attack and to evaluate the risk factors associated to its development. Methods: The 45 consecutive subjects who were admitted to our Division between January 1, 2015 and December 31, 2016 for severe acute asthma exacerbation underwent a diagnostic protocol including a standard chest X-ray and continuous monitoring of arterial oxygen saturation (SaO₂) during the first 24 hours following admission. The patients showing persistence or deterioration of oxyhemoglobin desaturation were prescribed a chest Computed Tomographic (CT) scan. Results: Five out of the 45 patients (11.1%) with severe acute asthma exacerbation were diagnosed with PNM, in one case on the basis of an X-ray image and in four on the basis of a chest CT scan. Data analysis showed that the PNM patients were younger [21 (17-21) vs 49.5 (20-73) yrs; p < 0.001] and more likely to show sensitization to Alternaria (2/5 vs 0/40; p = 0.0101) with respect to their non-PNM counterparts. The duration of hospital stay was similar in the two groups [8 (4-12) vs 7 (3-15) days; p = 0.6939]. Conclusions: PNM is a common clinical entity in young adults with severe acute asthma exacerbation, particularly in those with unsatisfactory response to initial medical therapy. Although generally benign, patients with suspected PNM should be closely monitored because of the risk of developing severe hypoxemia.

Spontaneous pneumomediastinum: A rare complication of methamphetamine use

OBJECTIVE

To present an unusual case of spontaneous pneumomediastinum subsequent to recreational amphetamine use.

CASE REPORT

A young African American adult male was admitted to internal medicine service for treatment of rhabdomyolysis secondary to methamphetamine use. On admission, he was complaining of chest pain in addition to nausea and generalized muscle aches. By his second hospital day, chest pain had resolved yet physical exam demonstrated crepitation of the anterior chest and left axilla. Portable chest x-ray revealed subcutaneous emphysema in addition to pneumomediastinum.

CONCLUSION

Spontaneous pneumomediastinum is a rare complication of amphetamine use that is often associated with subcutaneous emphysema and can be diagnosed with chest x-ray. Management is conservative, with observation, pain control, and supplemental oxygen as needed.

Diagnosis and treatment of spontaneous pneumomediastinum: experience at a single institution for 10 years

OBJECTIVE

The aim of this study was to identify appropriate method of diagnosis and treatment of spontaneous pneumomediastinum (SPM) based on our experience.

METHODS

The medical records of patients who were diagnosed with SPM and treated at our hospital between April 2006 and July 2015 were, retrospectively, analyzed. The data included characteristics of the patients, method of diagnosis, treatment and clinical course.

RESULTS

Forty-five patients were diagnosed with SPM and treated at our hospital. The mean age of patients was 18.96 ± 4.65 years and 35 patients were male. The main symptoms expressed by these patients were chest pain, throat pain or discomfort, and dyspnea. Nine patients had a precipitating event leading to SPM. Twelve patients had normal chest X-ray findings but were subsequently diagnosed with SPM on chest computed tomography (CT). Additional procedures including esophagogram (n = 36), bronchoscopy (n = 14) and endoscopy (n = 1) were done but none of patients were found to have organ damage. All patients received oxygen inhalation therapy. Oral intake was restricted in 36 patients and 43 patients received prophylactic antibiotics. The mean time taken for symptomatic improvement was 1.73 ± 0.85 days from diagnosis. The mean hospital stay was 3.93 ± 1.44 days and no patient developed recurrence of SPM during the follow-up period.

CONCLUSIONS

In addition to chest X-ray, chest CT is recommended for accurate diagnosis of SPM. However, further invasive investigations, restriction of oral intake and the use of prophylactic antibiotics have minimal role in the diagnosis and treatment of SPM.

Pneumomediastinum following Endobronchial Ultrasound- Guided Transbronchial Needle Aspiration: A Case Report

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an effective and safe technique associated with a very low complication rate for the sampling of lymph nodes in those presenting with mediastinal and hilar adenopathy." We report a rare case describing the development of pneumomediastinum following EBUS-TBNA in a young patient with mediastinal lymphadenopathy secondary to non-Hodgkin's lymphoma. Conservative treatment led to spontaneous resolution of the pneumomediastinum. Pneumomediastinum is a rare but possible complication of EBUS-TBNA. Careful follow-up can reduce its severity and the associated morbidity.