Pneumopericardium

Background

• Air in the pericardium
• Generally secondary to connection between pericardium and pleural cavity, bronchi, or GI tract
• Most often found following trauma, severe asthma exacerbation, strangulation, or forceful drug insufflation

Clinical Features

• May present with tamponade physiology depending on size
• Other features include:
  • Dyspnea
  • Cyanosis
  • Chest pain
  • Pulsus paradoxus
  • Bradycardia
  • Tachycardia

Differential Diagnosis

Causes of pneumopericardium

• GI malignancy
• PUD
• Esophageal diverticula
• Barotrauma
  • Mechanical ventilation
  • Vigorous bag-mask ventilation
  • SCUBA diving/rapid ascent
  • Drug insufflation (especially associated with crack cocaine)
• Asthma
• Valsalva
• Infection pericarditis with gas-producing bacteria
• Thoracic surgery
• Pericardial fluid drainage
• Blast injury
• Blunt or penetrating Thoracic trauma
• Neonatal respiratory distress syndrome

Evaluation

• Assess for underlying cause
• Assess vital signs for tamponade physiology (Beck's triad)
• Physical examination:
  • May have subcutaneous emphysema
  • May have succussion splash if there is also a pericardial effusion
  • May have Hamman crunch
• CXR
  • Heart partially or completely surrounded by gas
  • Pericardium sharply outlined by gas density on either side
  • Continuous diaphragm sign may be present (diaphragm seen continuously across the midline
• PoCUS
  • Bright spots moving along pericardial layer during diastole
  • Comet-tail artefacts extending across heart and disappearing during systole

Management

• Treat underlying cause
• Conservative management usually sufficient (usually self-resolves)
• If tamponade physiology, may require pericardiocentesis
  • If communicating pneumothorax, chest tube placement may resolve both

Disposition

• If underlying cause is stable and patient is asymptomatic, may discharge home
• Most patients will require admission for treatment of underlying cause