Pneumomediastinum: Difference between revisions
No edit summary |
No edit summary |
||
| Line 2: | Line 2: | ||
[[File:Subcutaneous emphysema chest cropped.jpg|thumb|Pneumomediastinum with subcutanous emphysema on CT.]] | [[File:Subcutaneous emphysema chest cropped.jpg|thumb|Pneumomediastinum with subcutanous emphysema on CT.]] | ||
*Also known as mediastinal emphysema | *Also known as mediastinal emphysema | ||
*Definition: air | *Definition: presence of free air in the mediastinum | ||
*Can be Spontaneous or secondary (to violation of aerodigestive tract)<ref name="Bakhos">Bakhos CT, Pupovac SS, Ata A, et al. Spontaneous pneumomediastinum: an extensive workup is not required. J Am Coll Surg. 2014 Oct;219(4):713-7. doi: 10.1016/j.jamcollsurg.2014.06.001.</ref> | |||
*Usually occurs due to sudden increase in intra-alveolar pressure causing alveolar rupture → air dissects into pulmonary interstitium and then into mediastinum, neck, or pericardium<ref name="Niehaus">Niehaus M, Rusgo A, Roth K, Jacoby JL. Retropharyngeal air and pneumomediastinum: a rare complication of influenza A and asthma in an adult. Am J Emerg Med. 2015 Jun 14. pii: S0735-6757(15)00495-7. doi: 10.1016/j.ajem.2015.06.020.</ref> | *Usually occurs due to sudden increase in intra-alveolar pressure causing alveolar rupture → air dissects into pulmonary interstitium and then into mediastinum, neck, or pericardium<ref name="Niehaus">Niehaus M, Rusgo A, Roth K, Jacoby JL. Retropharyngeal air and pneumomediastinum: a rare complication of influenza A and asthma in an adult. Am J Emerg Med. 2015 Jun 14. pii: S0735-6757(15)00495-7. doi: 10.1016/j.ajem.2015.06.020.</ref> | ||
*Life threatening causes include [[esophageal rupture]] or [[tension pneumothorax]] | *Life threatening causes include [[esophageal rupture]] or [[tension pneumothorax]] | ||
*If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is | *If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is typically a benign, self-limited condition. | ||
===Causes=== | ===Causes=== | ||
*Recreational drug use (via inhalation) - cocaine, methamphetamine, marijuana<ref name="Johnson">Johnson JN, Jones R, Wills BK. Spontaneous Pneumomediastinum. Western Journal of Emergency Medicine. 2008;9(4):217-218.</ref> | *Primary (spontaneous) pneumomediastinum | ||
*Hydrocarbon inhalation | **[[Asthma]]/[[COPD]] (Spontaneous or secondary to forceful coughing in the setting of bronchospasm) - most common co-morbidity<ref name="Bakhos" /> | ||
* | **Recreational drug use (via inhalation) - cocaine, methamphetamine, marijuana<ref name="Johnson">Johnson JN, Jones R, Wills BK. Spontaneous Pneumomediastinum. Western Journal of Emergency Medicine. 2008;9(4):217-218.</ref> | ||
*Influenza A<ref name="Niehaus" /> | **Hydrocarbon inhalation | ||
*[[ | **Influenza A<ref name="Niehaus" /> | ||
**Environmental [[pulmonary barotrauma]] (e.g. [[Scuba diving emergencies|scuba diving]], [[Commercial in-flight medical emergencies|flight]]) | |||
*Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest) | **Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest) | ||
*[[Mycoplasma pneumoniae]] [[pneumonia]] | **[[Mycoplasma pneumoniae]] [[pneumonia]] | ||
* | **[[Esophageal rupture]] (rare) | ||
*Iatrogenic - e.g. thoroscopy, VATS, bronchoscopy, colonoscopy or endoscopy | *Secondary pneumomediastinum | ||
*Blast injury | **Iatrogenic - e.g. thoroscopy, VATS, bronchoscopy, colonoscopy or endoscopy | ||
**Blast injury | |||
**[[Thoracic trauma]] | |||
==Clinical Features== | ==Clinical Features== | ||
*[[Chest pain]] | *[[Chest pain]] | ||
*[[Dyspnea]] | *[[Dyspnea]] | ||
*[[Subcutaneous emphysema]], especially of face, neck, and chest.<ref>Quresi SA, Tilyard A (2008). "Unusual Presentation of Spontaneous Mediastinum: A Case Report". ''Cases Journal'' 1:349. doi:10.1186/1757-1626-1-349</ref> | |||
*Voice change, cough, stridor | *Voice change, cough, stridor | ||
*"Crunching" sound on auscultation during systole (Hamman's crunch) | *"Crunching" sound on auscultation during systole (Hamman's crunch) | ||
*May mimic [[cardiac tamponade]]<ref>Beg MH, Reyazuddin, Ansari MM (1988). "Traumatic tension Pneumomediastinum Mimicking Cardiac Tamponade". ''Thorax'' 43:576-677. doi: 10.1136/thx.43.7.576.</ref> | *May mimic [[cardiac tamponade]]<ref>Beg MH, Reyazuddin, Ansari MM (1988). "Traumatic tension Pneumomediastinum Mimicking Cardiac Tamponade". ''Thorax'' 43:576-677. doi: 10.1136/thx.43.7.576.</ref> | ||
| Line 36: | Line 39: | ||
[[File:PneumoMediastinum2008.jpg|thumb|Traumatic pneumomediastinum and right sided pneumothorax with first rib fracture.]] | [[File:PneumoMediastinum2008.jpg|thumb|Traumatic pneumomediastinum and right sided pneumothorax with first rib fracture.]] | ||
[[File:Pneumomediastinum-003.jpg|thumb|Pneumomediastinum with Angel wing sign]] | [[File:Pneumomediastinum-003.jpg|thumb|Pneumomediastinum with Angel wing sign]] | ||
*CT Chest (preferred diagnostic test) | |||
*[[CXR]] | *[[CXR]] | ||
**AP/PA - Ring around right pulmonary artery, air along L heart border, air in upper chest/neck soft tissue | **AP/PA - Ring around right pulmonary artery, air along L heart border, air in upper chest/neck soft tissue | ||
**Lateral - air along anterior heart border | **Lateral - air along anterior heart border | ||
* | **30% with spontaneous pneumomediastinum will have normal CXR<ref name="Bakhos" /> | ||
==Management== | ==Management== | ||
| Line 47: | Line 51: | ||
==Disposition== | ==Disposition== | ||
* | *Spontaneous pneumomediastinum | ||
* | **Benign and self-limited disease | ||
**Generally does not require repeat imaging, and can be managed conservatively on an outpatient basis<ref name="Bakhos" /><ref>Fitzwater JW, Silva NN, Knight CG, et al. Management of spontaneous pneumomediastinum in children. J Pediatr Surg. 2015 Jun;50(6):983-6. doi: 10.1016/j.jpedsurg.2015.03.024.</ref> | |||
*Secondary pneumomediastinum<ref>de Virgilio C, Kim DY. Pneumomediastinum Following Blunt Trauma: Are We Closer to Unlocking Its Significance? JAMA Surg. 2015 Jun 24. doi: 10.1001/jamasurg.2015.1146.</ref> | |||
**Most cases are benign, but a minority of cases require additional testing and intervention. | |||
**Have lower threshold for additional testing and admission. | |||
==See Also== | ==See Also== | ||
Revision as of 05:45, 22 July 2015
Background
- Also known as mediastinal emphysema
- Definition: presence of free air in the mediastinum
- Can be Spontaneous or secondary (to violation of aerodigestive tract)[1]
- Usually occurs due to sudden increase in intra-alveolar pressure causing alveolar rupture → air dissects into pulmonary interstitium and then into mediastinum, neck, or pericardium[2]
- Life threatening causes include esophageal rupture or tension pneumothorax
- If no hemodynamic or airway compromise present, spontaneous pneumomediastinum is typically a benign, self-limited condition.
Causes
- Primary (spontaneous) pneumomediastinum
- Asthma/COPD (Spontaneous or secondary to forceful coughing in the setting of bronchospasm) - most common co-morbidity[1]
- Recreational drug use (via inhalation) - cocaine, methamphetamine, marijuana[3]
- Hydrocarbon inhalation
- Influenza A[2]
- Environmental pulmonary barotrauma (e.g. scuba diving, flight)
- Bowel rupture or other cause of air in abdominal cavity (tracts up into the chest)
- Mycoplasma pneumoniae pneumonia
- Esophageal rupture (rare)
- Secondary pneumomediastinum
- Iatrogenic - e.g. thoroscopy, VATS, bronchoscopy, colonoscopy or endoscopy
- Blast injury
- Thoracic trauma
Clinical Features
- Chest pain
- Dyspnea
- Subcutaneous emphysema, especially of face, neck, and chest.[4]
- Voice change, cough, stridor
- "Crunching" sound on auscultation during systole (Hamman's crunch)
- May mimic cardiac tamponade[5]
Differential Diagnosis
Chest pain
Critical
- Acute coronary syndromes (ACS)
- Aortic dissection
- Cardiac tamponade
- Coronary artery dissection
- Esophageal perforation (Boerhhaave's syndrome)
- Pulmonary embolism
- Tension pneumothorax
Emergent
- Cholecystitis
- Cocaine-associated chest pain
- Mediastinitis
- Myocardial rupture
- Myocarditis
- Pancreatitis
- Pericarditis
- Pneumothorax
Nonemergent
- Aortic stenosis
- Arthritis
- Asthma exacerbation
- Biliary colic
- Costochondritis
- Esophageal spasm
- Gastroesophageal reflux disease
- Herpes zoster / Postherpetic Neuralgia
- Hypertrophic cardiomyopathy
- Hyperventilation
- Mitral valve prolapse
- Panic attack
- Peptic ulcer disease
- Pleuritis
- Pneumomediastinum
- Pneumonia
- Rib fracture
- Stable angina
- Thoracic outlet syndrome
- Valvular heart disease
- Muscle sprain
- Psychologic / Somatic Chest Pain
- Spinal Root Compression
- Tumor
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Diagnosis
- CT Chest (preferred diagnostic test)
- CXR
- AP/PA - Ring around right pulmonary artery, air along L heart border, air in upper chest/neck soft tissue
- Lateral - air along anterior heart border
- 30% with spontaneous pneumomediastinum will have normal CXR[1]
Management
- Supportive care[3]
- Pneumomediastinum typically reabsorbs over 1-2 weeks.
- Treat underlying cause, if identified
Disposition
- Spontaneous pneumomediastinum
- Secondary pneumomediastinum[7]
- Most cases are benign, but a minority of cases require additional testing and intervention.
- Have lower threshold for additional testing and admission.
See Also
External Links
References
- ↑ 1.0 1.1 1.2 1.3 Bakhos CT, Pupovac SS, Ata A, et al. Spontaneous pneumomediastinum: an extensive workup is not required. J Am Coll Surg. 2014 Oct;219(4):713-7. doi: 10.1016/j.jamcollsurg.2014.06.001.
- ↑ 2.0 2.1 Niehaus M, Rusgo A, Roth K, Jacoby JL. Retropharyngeal air and pneumomediastinum: a rare complication of influenza A and asthma in an adult. Am J Emerg Med. 2015 Jun 14. pii: S0735-6757(15)00495-7. doi: 10.1016/j.ajem.2015.06.020.
- ↑ 3.0 3.1 Johnson JN, Jones R, Wills BK. Spontaneous Pneumomediastinum. Western Journal of Emergency Medicine. 2008;9(4):217-218.
- ↑ Quresi SA, Tilyard A (2008). "Unusual Presentation of Spontaneous Mediastinum: A Case Report". Cases Journal 1:349. doi:10.1186/1757-1626-1-349
- ↑ Beg MH, Reyazuddin, Ansari MM (1988). "Traumatic tension Pneumomediastinum Mimicking Cardiac Tamponade". Thorax 43:576-677. doi: 10.1136/thx.43.7.576.
- ↑ Fitzwater JW, Silva NN, Knight CG, et al. Management of spontaneous pneumomediastinum in children. J Pediatr Surg. 2015 Jun;50(6):983-6. doi: 10.1016/j.jpedsurg.2015.03.024.
- ↑ de Virgilio C, Kim DY. Pneumomediastinum Following Blunt Trauma: Are We Closer to Unlocking Its Significance? JAMA Surg. 2015 Jun 24. doi: 10.1001/jamasurg.2015.1146.