Spontaneous pneumomediastinum on bedside ultrasound: case report and review of the literature

A case of pneumomediastinum complicating immunotherapy associated pneumonitis

We describe the case of an 87-year-old gentleman referred to a metropolitan hospital in Sydney with pneumomediastinum complicating immunotherapy associated pneumonitis and recent bronchoscopic intervention. The contribution of pneumonitis in the setting of interstitial lung disease has been well described to developing pneumomediastinum however this is less clear in the setting of immunotherapy associated pneumonitis and to what extent bronchoscopic intervention compounds this risk.

Hamman Syndrome with a Rare Feature of Pneumorrhachis - An Unusual Complication of Polysubstance abuse and e-vaping

Hamman syndrome is defined as dissection of air in mediastinum and skin fascia usually due to increased intrathoracic pressure. The air leak tends to make its way into pleural and pericardial layers; however, in rare instances air can also dissect into epidural spaces, regarded as pneumorrhachis. We present a case of a young male with a history of polysubstance abuse and e-vaping, who presented with symptoms of altered mental status. Given the concerning physical examination, a computed tomography of the chest was undertaken, which showed pneumothorax, pneumomediastinum and pneumorrhachis. The patient was closely monitored in the intensive care unit and improved after symptomatic management. The symptoms of pneumorrhachis depend on the volume and location of air in intracranial and intraspinal space. Although asymptomatic in our case, it is crucial for clinicians to be aware that pneumorrhachis with Hamman syndrome can potentially cause neurological deficits and cardiopulmonary arrest in severe cases due to increased intraspinal and intracranial hypertension, emphasising the need for close monitoring.

LEARNING POINTS

Elevated intrathoracic pressure generated by deep inhalation of an aerosolised product is one of the triggers of air dissection in pleural, pericardial, and mediastinal regions. In rare instances, air can also translocate into intracranial and intraspinal spaces, which is referred to as pneumorrhachis.Mostly asymptomatic, pneumorrhachis has the potential to develop acute neurological deficits due to increased intracranial and intraspinal pressure, validating the need for acute monitoring.Most cases of pneumorrhachis are managed conservatively. However, severe cases warrant decompression or high concentrations of oxygen administration to facilitate air absorption.

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.

Case report: Severe pneumonia and pneumomediastinum in a previously robust adolescent caused by Omicron BA.5.2

The manifestation of severe pneumonia is only occasional, and pneumomediastinum is a condition that occurs rarely in Coronavirus disease 2019 (COVID-19) patients, especially in those patients who are infected with the Omicron variant. In addition, whether severe pneumonia or pneumomediastinum often occurs in patients in older age, in poor physical condition, or with underlying diseases remains to be ascertained. To date, severe pneumonia and pneumomediastinum due to Omicron infection had not been reported in a young patient with an excellent physical condition. In this study, we report such a case with the aforementioned manifestations in a robust adolescent infected with Omicron BA.5.2.

Iatrogenic Pneumopericardium in a Male Full-Term Newborn with Spontaneous Pneumothorax

Neonatal pneumopericardium, a collection of air in the pericardial sac, is less common form of air leak syndrome, but unfortunately with high mortality rate. We report a rare case of male fullterm newborn who soon after birth presented with respiratory distress. Chest radiograph showed spontaneous bilateral pneumothorax after which a chest drain was placed between anterior and midaxillary line in the 5th right intercostal space. The infant soon presented with tachypnea, dyspnea, muffled heart sounds, acidosis indicating cardiorespiratory worsening. On chest radiograph ‘’Halo” sign appeared indicating pneumopericardium. We believe that spontaneous reposition of a chest drain damaged the pericardial sac which combined with ventilation mechanism (‘’Macklin effect”) most likely led to pneumopericardium. After partial chest drain extraction the infant showed signs of improvement, but had to be closely monitored due to risk of tension pneumopericardium. Careful thoracal drain placement and fixation is crucial to prevent iatrogenic pneumopericardium, which can lead to deadly tension pneumopericardium.

[Spontaneous pneumomediastinum]

INTRODUCTION

Pneumomediastinum, which can be spontaneous or secondary, is defined by the presence of free air in the mediastinum as shown on a chest X-ray and/or chest CT, with or without subcutaneous emphysema. Secondary pneumomediastinum develops in various contexts (thoracic traumatism, perforation of central airway or digestive tract, pneumothorax, barotraumatism complicating mechanical ventilation…). Spontaneous pneumomediastinum , which will be the focus of this review, develops without any of the above-mentioned conditions.

STATE OF ART

Spontaneous pneumomediastinum is a rare entity which usually occurs in young people either without medical history or with an history of asthma. A trigger event is detected in 40% to 60% of cases. Positive diagnosis is made on chest radiographt but thoracic CT is more sensitive. Distinction between spontaneous pneumomediastinum and secondary pneumomediastinum is in general easy but may sometimes be more difficult, particularly in case of oesophageal perforation. The evolution of spontaneous pneumomediastinum is most often benign but, rare complications may occur. Management is most often conservative.

PERSPECTIVES

There is no consensual management of spontaneous pneumediastinum because of the lack of randomized prospective studies. This may be explained by the rarity of the disease. The actual trend is to offer to the patients a conservative treatment, which could be ambulatory in some cases.

CONCLUSIONS

Spontaneous pneumomediastinum is a rare entity developing mainly in young subjects. The evolution is in general benign, justifying a conservative approach.

Silent Dyspnea: Spontaneous Pneumomediastinum in a Heroin User

Spontaneous pneumomediastinum (SPM) is a relatively rare presentation that often follows a benign clinical course. It is mainly triggered by underlying bronchial asthma, respiratory tract infections, strenuous activities, or illicit drug use. We present a case of an isolated primary pneumomediastinum where the patient was a 24-year-old man with underlying bronchial asthma who presented with acute onset of shortness of breath and pleuritic chest pain following snorting of an opioid-heroin. Although the clinical exam and chest radiograph were both unremarkable, the multi-detector computed tomography of the chest revealed an isolated pneumomediastinum. The patient was managed conservatively in accordance with existing evidence as SPM is known for its spontaneous recovery.

A Rare Case of Vaping-Induced Spontaneous Pneumomediastinum

Vaping is the process of inhaling an aerosol produced by heating a liquid or wax containing substances such as nicotine, cannabinoids (e.g., tetrahydrocannabinol, cannabidiol), flavoring, and additives (e.g., glycerol, propylene glycol). The presence of air or gas in the mediastinum is pneumomediastinum.

We present a rare case of vaping-induced spontaneous pneumomediastinum. A young 20-year-old female patient with a history of vaping and no past medical history presented with acute chest pain to an emergency room. The urine drug screen was positive for cannabinoids. Imaging studies - chest x-ray and computed tomography of the chest - showed pneumomediastinum. The patient was discharged after a day of observation and counseling to quit vaping.

'Diagnosis of Boerhaave's Syndrome With Aid of Bedside Ultrasound

BACKGROUND

Boerhaave's syndrome is characterized by transmural rupture of the distal esophagus in the setting of increased intraluminal pressures combined with negative intrathoracic pressure. It is a rare condition with high mortality (20-50% mortality rate).

CASE REPORT

This is a case of a 47-year-old man who appeared acutely ill, presenting with shortness of breath, chest and abdominal pain, and diagnosed with Boerhaave's syndrome with the assistance of bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIANS BE AWARE OF THIS?: Emergency physicians must have a heightened suspicion of this diagnosis in patients presenting with chest and abdominal pain and can use bedside ultrasound skills to aid with diagnosis.

Cardiac A-lines in fast scan as a sign of pneumopericardium

Background

Traumatic pneumopericardium is rare and usually results from blunt injury. Diagnosis through clinical and chest X-ray is often difficult. Ultrasound findings of A-line artifacts in the cardiac window may suggest pneumopericardium.

Case presentation

A young man involved in a car accident and sustained blunt thoracic injuries, among others. As part of primary survey, FAST scan was performed. Subxiphoid view to look for evidence of pericardial effusion showed part of the cardiac image obscured by A-lines. Other cardiac windows showed only A-lines, as well. A suspicion of pneumopericardium was raised and CT scan confirmed the diagnosis.

Conclusions

Although FAST scan was originally used to look for presence of free fluid, with the knowledge of lung ultrasound for pneumothorax, our findings suggest that FAST scan can also be used to detect pneumopericardium.

Air and its Sonographic Appearance: Understanding the Artifacts

BACKGROUND

Although air has traditionally been considered a barrier to sonographic imaging, when encountered in unusual settings it can serve as an important indicator of various pathologic states as well. Clinician recognition and thorough understanding of the characteristic pattern of artifacts generated by air are critical for making a number of important diagnoses.

CASE SERIES

We present five emergency department cases in which air was visualized in a pathologic location. Pneumothorax, pneumoperitoneum, necrotizing fasciitis, or Fournier's gangrene, and subcutaneous emphysema and pneumomediastinum, can be rapidly and easily identified on ultrasound by the presence of air artifacts. The relevant sonographic findings are described and discussed in this article. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to its inherent impedance mismatch with other human tissues, air has a characteristic appearance on ultrasound that includes irregular hyperechoic structures, "dirty shadowing," A-lines, and decreased visualization of deeper structures. Knowledge of the sonographic appearance of air artifacts can assist the physician in making a diagnosis, selecting appropriate additional imaging, and enlisting specialist consultation.

Spontaneous pneumomediastinum in a healthy young female: A case report and literature review

Spontaneous pneumomediastinum (SPM) is an uncommon finding in young adults presenting usually without any comorbidities or an underlying pathology. It is most commonly due to alveolar rupture in the setting of an inciting event such an underlying asthma, barotrauma, valsalva maneuver, or esophageal rupture. Individuals can have varying presentations, from chest pain, dyspnea and dysphagia, to anxiety, weakness, or facial and neck swelling. The majority of patients have subcutaneous emphysema on examination and can have abnormal laboratory findings such as an elevated C-reactive proteins and leukocytosis. Diagnostic modalities used include chest x-ray, CT scan, ultrasound and barium swallow or esophagram. Majority of individuals and treated conservatively with rest, analgesia and oxygen administration. The prognosis of SPM is usually good with resolution within several days in most cases and the recurrence rate is very low. We report the case of a 22-year-old female presented with SPM diagnosed by chest x-ray and chest CT scan who was treated conservatively with subsequent spontaneous resolution.