Cent. Eur. J. Med.

• 9(5) • 2014 • 642-647

DOI: 10.2478/s11536-013-0311-1

Central European Journal of Medicine

Spontaneous pneumomediastinum: ten years of

our experience in diagnosis and outcome

Research Articlet

Sanja Hromis, Biljana Zvezdin, Ivan Kopitovic, Senka Milutinov,

Violeta Kolarov, Marija Vukoja, Bojan Zaric*

Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine, University

of Novi Sad, Serbia

Received 28 July 2013; Accepted 20 February 2014

Abstract: Spontaneous pneumomediastinum (SPM) is a rare clinical condition that may be mild but also dramatic with sudden onset of chest
pain and dyspnea accompanied by swelling and subcutaneous crepitations. The objective of this study was to analyze the clinical
presentation and outcome of SPM in a specialized pulmonary tertiary care centre over a 10 years year period. In subsequent follow-
up, we received information related to recurrence episodes of SPM by patients or their GPs physicians. Eighteen patients, 15 (83%)
men, mean age 24 years (SD ±7.86) were diagnosed with SPM. Predominant symptoms were chest pain and cough (n=11)
then dyspnea (n=9). Asthma was the most common predisposing condition (n=12). Pneumomediastinum was present on chest
radiograph in 17 cases (94%), and in one case it was detected only by computed tomography. The mean length of hospital stay
was 7 days (SD ±4.4 days). All our patients recovered and there were no complications. Recurrent event occurred in one asthma
patient, 2 years after the first episode. Although, SPM is usually a self-limiting and benign condition, close monitoring is necessary.
Recurrence is rare, but possible, with no evidence that routine monitoring of those patients is needed.
Keywords: Pneumomediastinum • Subcutaneous emphysema • Chest radiograph • Asthma • Hamman’s sign
© Versita Sp. z o.o

by various maneuvers. A forceful expiration against a

1. Introduction
Pneumomediastinum (PMD) is defined as the presence
of air or some other gas in the mediastinum. The known
causes of PMD occurrence are chest trauma, rupture of
the mucosal barriers or infections with gas forming mi-
croorganisms [1,2]. The term “spontaneous pnemuome-
diastinum” (SPM) was introduced by Louis Hamman in
1939 to describe PMD that occurred for no apparent
reasons [3]. According to the pathophysiological expla-
nation that was given in 1944 by Macklin and Macklin,
the existence of a pressure gradient between the alveoli
and lung interstitium can result in damage and rupture
of the terminal alveoli. This can cause air to leak into the
pulmonary interstitium. The higher pressure in the lung
interstitium is decompressed through vascular sheaths
to the soft mediastinal tissue where the pressure is lower
[4]. The development of the alveolar gradient is possible
closed airway can increase the intra-alveolar pressure
(Valsalva maneuver), the inspiration attempt with closed
mouth and nose reduces pleural pressure (Mueller
maneuver), while the intense work of breathing reduces
interstitial pressure [1]. Due to anatomical connections,
the air spreads from the mediastinum into the surround-
ing areas, leading to the development of subcutaneous
emphysema, pneumothorax, pneumopericardium,
pneumoperitoneum or pneumoretroperitoneum. In rare
cases, the air can accumulate into the mediastinum
and cause impaired venues return and cardiac function
resulting in hemodynamic and respiratory instability [5].
This condition is life threatening and requires an urgent
surgical intervention [6].
Clinical manifestations of SPM may vary from mild,
often unrecognized with discomfort in the chest or
cough, to a dramatic, sudden onset of severe chest
pain, dyspnea and swelling of the neck and face in a

* E-mail: bojanzaric@gmail.com
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S Hromis et al
previously healthy young PATIENTS. The clinical course
is usually benign and self limiting but rarely, severe or
even life threatening complications may develop [6]. It
is therefore important to recognize and understand this
condition in order to provide a safe management and
avoid undesirable outcomes.
The aim of this study was to determine the frequency
of SPM in a specialized tertiary pulmonary care centre,
discuss its presentations and outcomes. We also pre-
sented a review of the literature.
2. Materials and methods
It is a retrospective evaluation of patients admitted to the
Institute for Pulmonary Diseases of Vojvodina, Sremska
Kamenica, Serbia in whom spontaneous pneumomedi-
astinum was diagnosed, from January 2001 to Decem-
ber 2011. The cases were identified using patient charts
and hospital discharge data. All patients with chronic
lung diseases, other than asthma, were excluded from
the study. The following patient’s data were collected:
demographic data, precipitating factors or events that
immediately preceded the development of SPM, pre-
disposing conditions and diseases, symptoms, signs,
clinical findings, diagnostic investigations, treatment
and duration of hospitalization. In subsequent follow-up,
we received information related to recurrence episodes
of SPM by patients or their physicians. The study was
approved by the institutional review and ethics board.
The need for informed consent was waived due to the
observational study design.
3. Results
From January 2001 to December 2011, 71.077 patients
were admitted to the Institute for Pulmonary Diseases
of Vojvodina and 18 were diagnosed with spontaneous
pneumomediastinum. The incidence of SPM in our hos-
pital was approximately 1 per 4000 hospital admissions.
Among patients with SPM there were 15 men (83%) and
3 women (17%). The mean age was 24 years (range
18-47, SD ±7.86); 21 years (SD ±3) in men and 37 years
(SD ±12) in women (Table 1).
Precipitating events were found in 14 patients:
cough was reported in 11, bronchoconstriction in 10,
physical exercise in 2 and sneezing in one patient.
The absence of any specific triggers was observed in
4 cases. Asthma was the most common predisposing
condition identified in 12 patients while 2 patients had
upper respiratory infections. The majority of patients
were non-smokers (n=14, 78%). One patient had
concomitant hypothyreosis and one arterial hyperten-
sion; both were properly treated and regulated.
All patients had at least one symptom. Predominant
symptoms were chest pain and cough, both present
in 11 cases. Dyspnea was present in 9 cases (all in
asthma patients) and discomfort in the neck and chest
in 7 patients. Three patients presented with dysphonia
(Table 2). The most common sign was subcutaneous
emphysema, found in 17 patients (94%). It was present
in the neck and/or face in 12 patients (66%), over the
shoulders and upper chest in 4 patients (22%) and in 1
patient (5%) it affected the whole chest. Pathognomonic
Hamman’s sign was recorded in only 1 case (5%).
In all patients plain chest radiography was performed
as initial chest imaging and lateral view was performed
in 7 patients (Table 3). The most common radiographic
sign was subcutaneous emphysema, identified in 17 pa-
tients (94%) and continuous diaphragm sign identified in
12 cases (Figure 1). Computed tomography (CT) scan
of the chest was performed in 8 patients. The findings
confirmed PMD in 7 patients, and revealed pneumo-
mediastinum in one case with normal chest radiograph
(Figure 2).
In all patients some laboratory tests (complete blood
count, routine biochemistry, arterial blood gas analysis)
were performed. An elevated white blood cell count and/
or neutrophilia was found in 6 patients (33.3%) Arte-
rial blood gas analysis revealed respiratory failure in 9
patients (all with the acute asthma attack). Electrocar-
diogram (ECG) changes were found in 6 cases: slight
elevation of the ST segment in precordial leads in 4, and
T-wave inversion in lead III in 2 patients. However, all
these changes were not clinically significant.
The mean length of hospitalization was 7 days
(range 2-19, SD ±4.56 days). Treatment included rest
(100%), analgesia (55.5%), initial oxygen therapy
(50%), bronchodilatators (55%), corticosteroids (55%)
and antibiotics (33.3%). All patients recovered.
Information concerning recurrent episodes of SPM
was available in 16 patients, with the observation time
from 10 months to 10 years. A recurrent event occurred
in one asthma patient, 2 years after the first episode.
4. Discussion
An accurate incidence of SPM is rare and varies from
1:320 patients in a military hospital [7] and 1:44.511
patients in critical care settings [1]. We recorded a high
incidence in our series that was approximately 1:4000,
probably due to selected pulmonary patients, who pre-
sented as lung emergency.
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 Spontaneous pneumomediastinum

Table 1. Patient’s Demography, Predisposing and Precipitating Factors, Radiology Performed and Follow-Up

Plane/ length of
Smoking Follow-
No. gender Age(y) Predisposing Disease Precipitating Event Lateral Chest CT Scan hospital
(p/y) Up (days)
Roentgenogram stay (days)
1 m 23 3 URTI cough +/- 2 1882
2 f 24 None none none +/- 4 2249
3 f 41 None asthma none +/- 3  987
bronchoconstriction
4
m 18 none asthma cough +/- 2 1856
5 m 23 5 none sneezing +/- 3 388
6 m 21 none none none +/- 4 1789
bronchoconstriction
7
m 19 none asthma cough +/+ + 12 252
bronchoconstriction
8
m 18 none asthma cough +/+ 11 1923
bronchoconstriction
9
m 20 none asthma cough +/+ + 8 2245
bronchoconstriction
10
m 18 none asthma hypothyreosis cough +/+ + 8 1528

11 asthma AND bronchoconstriction

m 27 7 ARTERIAL. hypertension cough +/- + 8 1818
bronchoconstriction
12
m 23 none asthma cough +/+ + 11 3008
bronchoconstriction
13
m 18 none asthma cough +/- + 7 3282
bronchoconstriction
14
f 47 none asthma cough +/+ + 19 1746
15 m 20 none  asthma, URTI none +/- 4 * 984
bronchoconstriction
16
m 21 none asthma cough +/+ + 10 3612
17 m 23 5 none exercise +/- 9 -
18 m 22 none none exercise +/-   5  3281
*recurrent event 724 days after first episode
URTI - upper respiratory tract infection

Table 2. Symptoms and Signs

Symptoms No. % Signs No. %

Cough 11 61 Subcutaneous emphysema 17 94

Chest pain 11 61 Neck or face 12 66

Dyspnea 9 50 Shoulders und upper chest 4 22

Discomfort (neck/chest) 7 39 Whole chest 1 5

Dysphonia 3 17 Hamman’s sign 1 5

Absence of triggers 4 22

Some patients had more than one symptom

Different triggering factors can precede the devel-
opment of SPM including; sneezing, coughing, hard
exercise, weight lifting, diving, inflating party balloons,
spirometric maneuvesr, labor, consumption of inhaled
drugs and many others [1,8]. In many cases, the
triggering factors are not known. SPM often develops in
young, tall men [7,8] while smoking is not found to be a
risk factor [4,9]. Consistent with that, 83% of our patients
were young men and among them 12% were smokers,
though smoking is not found to be a risk factor [4,9].

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S Hromis et al
Table 3. Radiographic examinations
Radiographic testing
Plain chest
subcutaneous emphysema
continuous diaphragm sign
vertical line of radiolucency
double bronchial-wall sign
extrapleural-air sign
Lateral view
ring-around-the-artery sign
continuous left hemidiaphragm sign
pronounced pulmonary artery and aorta
There is no consensus whether the development of
PMD in the presence of the underlying lung diseases
should be considered as spontaneous. However, SPM
was reported in patients with emphysema and bronchi-
ectasis by Iyer [10], interstitial lung diseases by New-
combs [8] or chronic obstructive pulmonary disease by
Careras [11]. Asthma has been reported as the most
common predisposing condition, found in 8-39% of
SPM [1,8,11]. In case of asthma, bronchoconstriction
and hyperinflation are considered the main causes of a
spontaneous alveolar rupture. The influence of asthma
remodeling has not been studied yet. However, it should
be noted that asthmatics have an increased risk for
SPM even without an active bronchospasm. Out of 12
patients with asthma identified in our study, 10 had an
acute asthma attack, nine of whom developed respira-
tory failure. In two patients no signs of bronchoconstric-
tion were identified.
Figure 1. Chest-X Ray, arrows 1-3 pointing the air collections in the
mediastinum.
The clinical manifestation of SPM varies from
No. mild to severe. The most common symptoms are the
18
chest pain and dyspnea [8,1]. The chest pain is typi-
cally sharp, acute, retrosternal, radiates to the neck or
17
shoulders and may worsen with inspiration [12]. Other
12
symptoms include fever, dysphonia, sore throat, and
12
dysphagia [4,8]. A remarkable clinical sign is subcutane-
4 ous emphysema with crepitations and swelling, present
0 in 76-90% of patients [8]. In recent studies, a pathogno-
7 monic Hamman’s sign or mediastinal crunching sound
3 synchronous with the heartbeat have been identified
5 in solely 0-12% of patients [4,12]. The sign is difficult
1 to detect and requires a careful auscultation on the left
lateral position. Our results are consistent with formerly
published studies.
The basic diagnostic procedure for revealing PMD is
a radiographic examination. Subcutaneous emphysema
is easily detected and represents the most common
radiographic finding. The typical posterioanterior ra-
diographic signs are: a continuous diaphragm sign, a
double bronchial-wall sign, the extrapleural-air sign and
the vertical line of radiolucency along the left cardiac
border or in the superior mediastinum [13]. The lateral
view allows detection of a smaller amount of free air that
can be revealed as ringaround-the-artery sign or con-
tinuous left hemidiaphragm sign. Still, CT of the chest
remains a gold standard for the diagnosis of SPM [14].
In our study, the radiographic examination was sufficient
for the diagnosis in majority of the patients, while CT
was needed to establish the diagnosis in only one case.
Other diagnostic procedures are not specific. Mild
inflammatory signs may be found OUTSIDE THE
AFFECTED MEDIASTINUM [4]. Arterial blood gas
analysis is recommended if there is evidence of severe
bronchoconstriction. Changes on ECG without clinical
Figure 2. CT scan of the chest. Arrows pointing the air collections
in the mediastinum
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significance have been described by some authors [4].
We found leukocytosis with neutrophilia in six patients,
respiratory failure in 9 acute asthma patients, and slight
elevation of the ST segment and T-wave inversion on
ECG in 6 patients.
The differential diagnosis should be performed care-
fully. An urgent diagnosis and endoscopic evaluation is
necessary if PMD is accompanied with chest trauma,
intense vomiting, previously endoscopic diagnostic pro-
cedures or mediastinal infections [2,14]. Pneumothorax,
pulmonary embolism, acute coronary syndrome and
pericarditis have also to be excluded [1]. In our series,
one fiberoptic bronchoscopy was performed in the pa-
tient with acute asthma complicated with posterobasal
left atelectasis and SPM. During the procedure, a mucus
plug was removed which further led to the stabilization
and recovery of the patient.
Complications of SPM are rare. Simple pneumotho-
rax [4,8], unilateral tension pneumothorax [5] and only
recently, a life threatening tension pneumomediastinum
in an acute asthma patient [6] have alredy been reported
in the literature. In our series, there were no complica-
tions of SPM.
No specific treatment of SPM is required. Hospital
observation has been suggested [10], although an
outpatient management is possible if the symptoms are
mild and tolerable [16]. The main approaches are rest
and analgesia. A high concentration of oxygen is some-
times used [12], but there is no evidence about its effi-
cacy [4]. Underlying diseases like upper airway infection
or asthma exacerbations require appropriate treatment.
The prophylactic use of antibiotics is not recommended
[4]. The resolution of air is expected within 3-4 days. We
reported mean length of hospitalization for 7 days that
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5. Conclusions
We can conclude that SPM is a rare, usually self-limiting
and benign condition that can complicate acute asthma
exacerbations. Hospital observation is recommended
because of the risk of severe complications. The differ-
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is no need for additional radiographic or endoscopic ex-
aminations in a clear clinical manifestation. Recurrence
is rare but possible, without evidence that monitoring of
those patients is needed.
Conflict of interest statement
Authors state no conflict of interest.
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