Pneumomediastinum

* Rare Condition

* More Common Among Children

and Neonates

First Described By Laennec 1819 as

a consequence of Traumatic Injury
Then Spontaneous
Pneumomediastinum was described
by Hamman in 1939
It is defined as free air or gas
contained within the mediastinum,
which almost invariably originates
from the alveolar space or the
conducting airways.
Pneumomediastinum

Spontaneous

Traumatic
 Spontaneous

Rupture of Marginally Situated

Alveoli (high intraalveolar
pressure)

Erosion of a Tracheal Or
Esophageal Tumor

Pneumoperitoneum,
Pneumoretroperitoneum
 Traumatic

pulmonary interstitial
emphysema (positive pressure
ventilation)

ruptured bronchus (commonly

associated with pneumothorax)

ruptured esophagus (diabetic

acidosis, alcoholic, Boerhaave)
Pathophysiology

The Macklin Effect 1944

o alveolar rupture

o air dissection along the

bronchovascular sheath

o free air reaching the

mediastinum
 Complications
Rarely leads to significant
complications by it self
Comorbid
Significant Illness Disease

Trauma
Tension
Pneumomediastinum
Rare
Elevated Mediastinal pressure leads to
diminished cardiac output, either by:

direct cardiac compression

reduced venous return

When extensive subcutaneous and

mediastinal gas is present, airway
compression may also occur.
Statistics
SPM
from 1 per 800 to 1 per 42,000 pediatric
patients presenting to ER.
from 1 per 12,000 to 1 per 30,000
admission to the hospital.
0.3% incidence of PM in association with
asthma over a 10-year period.

TPM
10% of blunt chest injury patients will
develop PM.
Mortality & Morbidity
SPM is a self limited condition

are generally attributable to underlying

disease states.
as high as 50-70% as seen in
Boerhaave syndrome

is not associated with an

increased mortality rate in
patients with sepsis-induced
ARDS
Gender

29 cases of SPM over a 10-year

period, 69% were males
Is a body habitus favoring a tall thin build is
an additional risk factor for the
development of SPM?

TPM is more common in males,

reflecting the male
predominance among those
who experience trauma and
accidents.
 Age
The peak prevalence of SPM is seen in the second
to fourth decades of life.

reflects involvement in activities that

increase the risk of developing SPM

the force of an individual's cough, vomit, and Valsalva

maneuvers (all of which may lead to PM) attenuates with age

The age distribution for PM occurring in

conjunction with specific disease
processes reflects the age profile of the
particular disease.
Clinically
Chest pain
Dyspnea
Fever
Dysphonia
Throat pain
Jaw pain
Miscellaneous :
Dysphagia, neck swelling, and torticollis
 Chest pain

IN SPM said to be a feature in 50-90% of cases

retrosternal in location
worsened by inspiratory maneuvers
may radiate to the shoulders or back thus
suggesting MI or pericarditis

in 27% of persons with

asthma with PM
 Dyspnea

may reflect associated illnesses such

as asthma, a coexistent pneumothorax,
or a tension PM.
 Fever
Low-grade fever may be present

following cytokine release that is

associated with air leak.

mediastinitis or infectious/inflammatory
disorders should be included in the
differential diagnosis

Dysphonia
 Signs
Subcutaneous air

The Hamman sign

Associated pneumothorax

Other diseases

Oxygen saturation
Subcutaneous air

not pathognomic of PM

subcutaneous emphysema in 73% of

patients presenting with asthma
subsequently found to have PM.

The positive predictive value of this sign

for PM in the previous series was 100%.
The Hamman sign
pathognomic of PM

precordial systolic crepitations

and diminution of heart sounds

prevalence of 10% to 50% PM

patients
Oxygen saturation

Pulse oximetry is mandatory in

all patients with suspected PM

In a series of children with

asthma presenting to an
emergency department, those
with PM had a significant
difference in oxyhemoglobin
saturation (90% vs 94% of
those without PM, p = 0.03).
 Work Up

Chest X-Ray
usually reveals a pneumomediastinum.

thymic sail sign

"ring around the artery"

sign

double bronchial wall sign

continuous diaphragm sign

the extrapleural sign

spinnaker sail
sign
Subcutaneous
air
continuous diaphragm sign
 CT-Scan
provideadditional diagnostic
information regarding the
presence of coexisting illness
in diagnosing small
pneumomediastinum not visible
on chest radiography.

chest radiography alone

may result in a missed
diagnosis in 10% of
patients presenting with
pneumomediastinum.
Contrast radiography
suspected esophageal perforation

ABG

ECG
Spirometry

?
should not be undertaken in
patients with
pneumomediastinum

because the increased

alveolar pressures may
further exacerbate the air
leak.
Treatment
Medical Care
Most are Asymptomatic
Spontaneously resolve

Adequate analgesia

Some Points
mechanical ventilation & PM?
high-frequency oscillatory ventilation
Children with ARDS and PM?
Nitrogen washout with inhalation of
100% oxygen
Mechanical Ventilation & PM?

The use of the lowest pressures or tidal

volumes necessary to achieve satisfactory
carbon dioxide removal and oxygenation.

Permissive hypercapnia, a ventilatory strategy that

is based on maintaining adequate oxygenation and
blood pH while allowing high partial pressure of
carbon dioxide, allows for ventilatory support while
minimizing barotrauma.
Treatment
Surgical Care

Mediastinoscopy

Mediastinal drainage
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