Clinical analysis of spontaneous pneumomediastinum

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.

Clinical use of Macklin-like radiological sign (Macklin effect): A systematic review

INTRODUCTION

Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to further characterize the clinical role of Macklin.

METHODS

PubMed, Scopus, Cochrane Central Register and Embase were searched for studies reporting data on Macklin. Studies without data on chest CT, pediatric studies, non-human and cadaver studies, case reports and series including <5 patients were excluded. The primary objective was to assess the number of patients with Macklin sign and barotrauma. Secondary objectives were: occurrence of Macklin in different populations, clinical use of Macklin, prognostic impact of Macklin.

RESULTS

Seven studies enrolling 979 patients were included. Macklin was present in 4-22% of COVID-19 patients. It was associated with barotrauma in 124/138 (89.8%) of cases. Macklin sign preceded barotrauma in 65/69 cases (94.2%) 3-8 days in advance. Four studies used Macklin as pathophysiological explanation for barotrauma, two studies as a predictor of barotrauma and one as a decision-making tool. Two studies suggested that Macklin is a strong predictor of barotrauma in ARDS patients and one study used Macklin sign to candidate high-risk ARDS patients to awake extracorporeal membrane oxygenation (ECMO). A possible correlation between Macklin and worse prognosis was suggested in two studies on COVID-19 and blunt chest trauma.

CONCLUSIONS

Increasing evidence suggests that Macklin sign anticipate barotrauma in patients with ARDS and there are initial reports on use of Macklin as a decision-making tool. Further studies investigating the role of Macklin sign in ARDS are justified.

A narrative review of primary spontaneous pneumomediastinum: a poorly understood and resource-intensive problem

Primary spontaneous pneumomediastinum (PSPM) is a benign self-limited condition that can be difficult to discriminate from esophageal perforation. This may trigger costly work-up, transfers and hospital admissions. To better understand this diagnostic dilemma and current management, we undertook the most comprehensive and up to date review of PSPM. The PubMed database was searched using the MeSH term "Mediastinal Emphysema"[Mesh], to identify randomized controlled trials, meta-analyses and case series (including 10 or more patients) relevant to the clinical presentation and management of patients with PSPM. There were no relevant randomized controlled trials or meta-analyses. Nineteen case series met our criteria, including a total of 535 patients. The average mean age was 23 years with a 3:1 male predominance. Chest pain was the most common symptom, found in 70.9% of the patients. Dyspnea and neck pain were the second and third most common symptoms, found in 43.4% and 32% of the patients, respectively. Subcutaneous emphysema was the most common sign (54.2%). Common histories included smoking (29.6%), cough (27.7%), asthma (25.9%), physical exertion (21.1%) and recent retching or emesis (13%). Nearly all patients (96.9%) underwent chest X-ray (CXR). Other diagnostic studies included computed tomography (65%) and esophagram (35.6%). Invasive studies were common, with 13% of patients undergoing esophagogastroduodenoscopy and 14.6% undergoing bronchoscopy. The rate of hospital admission was 86.5%, with an average length of stay of 4.4 days. No deaths were reported. Notably, we identified a dearth of information regarding the vitals, laboratory values and imaging findings specific to patients presenting with PSPM. We conclude that PSPM is a benign clinical entity that continues to present a resource-intensive diagnostic challenge and that data on the vitals, labs, and imaging findings specific to PSPM patients is scant. An improved understanding of these factors may lead to more efficient diagnosis and management of these patients.

Spontaneous primary pneumomediastinum: is it always benign?

BACKGROUND

Spontaneous Pneumomediastinum is a rare disease. It could be a simple and self-limited condition or be a life-threatening complication of underlying diseases. The therapeutic options also differ by the cause. This systematic review was done to provide, as far as we know, the first attempt to broadly assess the clinical feature, predisposing factors, possible management, and outcome of spontaneous primary pneumomediastinum.

METHODS

In addition to the two patients treated at our hospital, a Pub Med Search for literature on case reports of spontaneous pneumomediastinum published in English up to November 2018 was done. We extracted data on patients' demographic characteristics, symptoms, timing, diagnosis, management, and outcome of the treatment were analyzed based on the preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) RESULT: A total of 339 cases were reviewed. 71.7% of them were male. The Mean age affected was 22.4 ± 11.3 years. Chest pain, 196 (57.8%), is the most common presenting symptom, followed by dyspnea, 156 (46%), cough 95 (28%), neck swelling 92 (27.13%), cervical pain 88 (25.9%), dysphagia 39 (11.5%), odynophagia 37 (10.9%), and Dysphonia 14 (4.1%). Fifty-seven patients (16.8%) had a prior history of Asthma, 19 (5.6%) had Connective Tissue Disorders, and 12 (3.5%) had associated malignancy as an identified risk factor. In 35 (10.3%) patients, spontaneous pneumomediastinum was found incidentally. The mean number of days before the clinical resolution of spontaneous pneumomediastinum was 6.65 ± 11.8 days and the average hospital stay was 4.15 ± 1.93 days. Nineteen (5.6%) patients have died as a result of the underlying disease not related to SPM.

CONCLUSION

Spontaneous pneumomediastinum is uncommon, usually benign, a self-limited disorder that commonly occurs in a young adult without any apparent precipitating factor or disease. Spontaneous pneumomediastinum usually responds very well to conservative treatment without recurrence. However, secondary causes should be ruled out to minimize the unfavorable outcome.

Spontaneous Pneumomediastinum: Analysis of 11 Cases

Objectives:

The presence of free air in mediastinum is defined as pneumomediastinum. The incidence is between 1/7000-1/32000. In this study, our aim is to discuss our cases with spontaneous pneumomediastinum (SPM), which has low incidence, in the light of the literature.

Methods:

The files of 11 cases who were diagnosed with SPM in pulmonary diseases and thoracic surgery department and followed up and treated in thoracic surgery clinic between 2012-2018 were retrospectively analyzed. Patients’ age, sex, etiological factors, diagnosis and treatment methods and hospital stay were evaluated.

Results:

Between the years of 2012-2018, 11 cases with SPM who were not related to trauma were detected. Nine (81.8%) of the patients were male; the median age was 38.5 years. Among the predisposing factors that played a role in the formation of SPM, the most common symptom was dyspnea, while the second most common symptom was coughing seizures. The median duration of hospitalization was 3.8 days, and no mortality was observed.

Conclusion:

Spontaneous pneumomediastinum is a rare clinical condition, especially in young men. SPM treatment can be conservative or surgical.

Spontaneous pneumomediastinum incidence and clinical features in non-intubated patients with COVID-19

OBJECTIVES

To evaluate the presentation characteristics and disease course of seven patients with COVID-19 who spontaneously developed pneumomediastinum without a history of mechanical ventilation.

METHODS

A total of seven non-intubated patients with COVID-19, of age ranging from 18-67 years, who developed spontaneous pneumomediastinum between 01 April and 01 October 2020 were included in the study. Patients' demographic data, clinical variables, and laboratory values were examined. Spontaneous pneumomediastinum was evaluated using posteroanterior chest radiography and thorax computed tomography.

RESULTS

During the research period, 38,492 patients reported to the emergency department of our hospital with COVID-19 symptoms. Of these, spontaneous pneumomediastinum was detected in seven patients who had no previous history of intubation. Chronic obstructive pulmonary disease (2/7) and asthma bronchiale (2/7) were determined as the most common causes of comorbidity.

CONCLUSIONS

In our study, the frequency of spontaneous pneumomediastinum developing without pneumothorax was found to be high in non-intubated patients. Whether this is related to the nature of the disease or it is a result of the increase in cases diagnosed incidentally owing to the increasing use of low-dose computed tomography should be explored in further studies.

Left-sided Neck Swelling: An Unusual Presentation of a Rare Disease

Pneumomediastinum describes air infiltrating into the soft tissues of the mediastinum. It may be classified as spontaneous or secondary. Spontaneous pneumomediastinum is a rare disease, which usually resolves without intervention. The acute onset of chest pain is the most common presenting complaint.  This article presents a case of spontaneous pneumomediastinum in a 19-year-old man with a short history of rapidly enlarging, painless swelling to the left side of his neck, followed by a discussion of the literature. The diagnosis was made following chest x-ray (CXR) and computed tomography (CT). There was no history of any precipitating event or any risk factors. He was managed conservatively and discharged with outpatient follow-up.  Management of spontaneous pneumomediastinum continues to vary and may benefit from the development of guidelines to standardise management in the future.

Spontaneous pneumomediastinum: experience in 18 patients during the last 12 years

Objective:

To characterize clinically all of the patients with spontaneous pneumomediastinum (SPM) admitted to an adult pulmonology ward in Lisbon, Portugal.

Methods:

This was a retrospective descriptive study of all adult patients (≥ 18 years of age) diagnosed with SPM between January of 2004 and September of 2015.

Results:

At least one predisposing factor was identified in most (88.9%) of the 18 patients who presented with SPM during the study period. With regard to precipitating factors, bouts of cough were present in 50.0% of the patients. Other precipitating factors included a sudden increase in tobacco consumption, inhaled drug use, occupational inhalation of varnish fumes, intense exercise, and vomiting. The most common complaints were dyspnea (in 83.3%) and chest pain (in 77.8%). Other complaints included cough, neck pain, dysphagia, and odynophagia. Subcutaneous emphysema was found in most of the patients. The diagnosis of SPM was based on chest X-ray findings in 61.1% of the patients.

Conclusions:

Although SPM is a rare condition, it should be considered in the differential diagnosis of chest pain and dyspnea. It can develop without a triggering event or conclusive findings on a chest X-ray, which is usually sufficient for diagnosis.

Pediatric Spontaneous Pneumomediastinum: Narrative Literature Review

INTRODUCTION

Described since 1939 in the adult population, spontaneous pneumomediastinum is less known in children. Because of its symptoms and a generally benign evolution, it is probably an underestimated diagnosis. However, it has to be considered in the differential diagnosis of acute thoracic pain.

METHODS

The incidence being low, we conducted a narrative literature review to identify the circumstances leading to a spontaneous pneumomediastinum, the most relevant signs and symptoms, investigations, as well as treatment recommendations.

RESULTS

Of 216 patients, 66.2% are boys, and mean ages range from 6.9 to 14 years. The most frequent comorbidity in children is asthma (22.2%), and the most common trigger factors are bronchospasm (49%), cough (45.6%), various respiratory tract infections, vomiting (10.3%), and foreign body aspiration (8.3%). It remains idiopathic in 33.3%. Relevant signs are chest pain (54.6%), neck pain and/or sore throat (53.3%), and dyspnea (41.2%). The most relevant sign is palpation of subcutaneous emphysema (66.4%). The classically described Hamman crunch is only present in 11.6%. Chest x-ray provides the right diagnosis in 99.5% of the patients. Pneumothorax is associated in 11.6%. Most patients are hospitalized (88.3%); treatment is based on oxygen therapy, painkillers, and rest. In some series, there can be up to 25.8% of patients requiring intensive care and 5.5% requiring drainage of associated pneumothorax. Survival rate is 92.5%, and long-term follow-up shows normal x-rays after 4 days and no recurrence.

CONCLUSIONS

Spontaneous pneumomediastinum is uncommon in children but must be considered in pediatric patients with acute chest and/or neck pain. History taking, physical examination, and standard chest x-ray are most often diagnostic, and there is rarely a need for other investigation.Hospitalization is not always indispensable; ambulatory management can be considered. Outcome is good, and follow-up can be clinical, therefore avoiding further x-rays.

IMAGING DIAGNOSIS-SPONTANEOUS PNEUMOMEDIASTINUM SECONDARY TO PRIMARY PULMONARY PATHOLOGY IN A DALMATIAN DOG

A 1.5-year-old, 23 kg intact male Dalmatian dog was evaluated for acute respiratory insufficiency without a previous history of trauma or toxic exposition. Imaging revealed pneumomediastinum, pneumothorax, diffuse unstructured interstitial pulmonary pattern, pulmonary interstitial emphysema, and pneumoretroperitoneum. Histopathological evaluation of the lungs revealed perivascular and peribronchial emphysema, mild lymphocytic interstitial pneumonia with atypical proliferation of type II pneumocytes in bronchioles and alveoli. A lung disease resembling fibrosing interstitial pneumonia in man and cats has been previously reported in Dalmatians and should be included as a differential diagnosis for Dalmatians with this combination of clinical and imaging characteristics.

Tracheal diverticulum masquerading as pneumomediastinum in a trauma victim

BACKGROUND

The differential diagnosis for a paratracheal air collection includes Zenker diverticulum, tracheal diverticulum, apical herniation of the lung, and pneumomediastinum. In the setting of trauma, pneumomediastinum is traditionally regarded as an alarm sign that warrants investigation for tracheal or esophageal rupture,both highly morbid conditions.

CASE REPORT

A patient presented to the emergency department with neck pain several hours after being involved in a low-speed,side-impact automobile collision. She was discharged with analgesics after cervical spine radiographs showed no fracture and physical examination found no neurological deficits. She returned 18 days later with retrosternal pain and worsening neck pain, and cervical computed tomographic scan demonstrated an abnormal paratracheal air collection. Follow-up chest computed tomographic scan identified a right-sided tracheal diverticulum without evidence of pneumomediastinum.

Spontaneous pneumomediastinum with a rare presentation

Spontaneous pneumomediastinum is an unusual and benign condition in which air is present in mediastinum. A 20-year-old male patient presented to ED with complaint of hoarseness and odynophagia from the day before, after weightlifting. The patient was nonsmoker and denied history of other diseases. On physical examination he had no dyspnea with normal vital signs. Throat examination and pulmonary auscultation were normal and no crepitation was palpable. We could not find subcutaneous emphysema in neck and chest examination. In neck and chest X-ray we found that air is present around the trachea. There was no apparent pneumothorax in CXR. In cervical and chest CT free air was present around trachea and in mediastinum. Subcutaneous emphysema was also evident. But there was no pneumothorax. The patient was admitted and went under close observation, oxygen therapy, and analgesic. The pneumomediastinum and subcutaneous emphysema gradually resolved within a week by conservative therapy and he was discharged without any complication. Many different conditions could be trigged because of pneumomediastinum but it is rarely seen in intense physical exertion such as weightlifting and bodybuilding. Two most common symptoms are retrosternal chest pain and dyspnea. But the patient here complained of hoarseness and odynophagia.