Persistent pneumomediastinum in interstitial fibrosis associated with rheumatoid arthritis: treatment with high-concentration oxygen

[Pneumomediastinum as a rare complication in connective tissue disease]

Otherwise known as mediastinal emphysema, pneumomediastinum (PNM) in connective tissue diseases is a rare clinical entity. Few cases have been described in the literature. In fact, it only exceptionally complicates the evolution of connective tissue diseases. In this paper report, two cases of spontaneous PNM secondary to scleroderma and Sjogren's syndrome. Based on the data in the literature, we discuss the etiology, frequency of occurrence, and the pathophysiological mechanisms of this unusual complication.

Spontaneous pneumomediastinum and pneumopericardium in a young male with asthma

INTRODUCTION

Spontaneous pneumomediastinum with pneumopericardium is an uncommon clinical entity.

CASE STUDY

Here, we report the case of a 23-year-old male with asthma who presented with acute chest pain and shortness of breath after an episode of coughing and sneezing. CT scans of the chest and neck revealed pneumomediastinum and pneumopericardium with extensive subcutaneous emphysema extending into the axilla and neck.

RESULTS

The patient was admitted for observation and analgesia. No other interventions were administered. Interval scans performed on day five of the admission demonstrated an interval reduction in the degree of air within the mediastinum, pericardium and subcutaneous tissues, and the patient was subsequently discharged home.

CONCLUSION

This case outlines the presentation, diagnosis, and management of concurrent spontaneous pneumomediastinum and pneumopericardium.

Spontaneous pneumomediastinum in anti-MDA5-positive dermatomyositis: Prevalence, risk factors, and prognosis

OBJECTIVE

To depict the clinical panorama of spontaneous pneumomediastinum (SPM) in anti-MDA5 antibody-positive dermatomyositis (anti-MDA5+ DM).

METHODS

A total of 1352 patients with idiopathic inflammatory myopathy (IIM), including 384 anti-MDA5+ DM patients were retrospectively enrolled. The clinical profiles of anti-MDA5+ DM-associated SPM were analyzed.

RESULTS

We identified that 9.4 % (36/384) of anti-MDA5+ DM patients were complicated with SPM, which was significantly higher than that of non-anti-MDA5+ DM and other IIM subtypes (P all <0.001). SPM developed at a median of 5.5 (3.0, 12.0) months after anti-MDA5+ DM onset. Anti-MDA5+ DM patients complicated with SPM showed a significantly higher frequency of fever, dyspnea, and pulmonary infection including viral and fungal infections compared to those without SPM (P all < 0.05). Cytomegalovirus (CMV) and fungal infections were identified to be independent risk factors for SPM development in the anti-MDA5+ DM. SPM and non-SPM patients in our anti-MDA5+ DM cohort showed comparable short-term and long-term survival (P = 0.236). Furthermore, in the SPM group, we found that the non-survivors had a lower peripheral lymphocyte count, higher LDH level, and higher frequency of intensification of immunosuppressive treatment (IST) than survivors. The elevated LDH level and intensification of IST were independent risk factors for increased mortality in anti-MDA5+ DM-associated SPM patients.

CONCLUSIONS

Nearly one-tenth of patients with anti-MDA5+ DM develop SPM. Both CMV and fungal infections are risk factors for SPM occurrence. The development of SPM does not worsen the prognosis of anti-MDA5+ DM patients, and the intensification of IST does harm to the SPM prognosis.

Pulmonary air leak syndrome in rheumatoid arthritis patient

Pulmonary air leak syndromes involve dissection of air out of the normal pulmonary airspaces and include pulmonary interstitial emphysema, pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, subcutaneous emphysema and systemic air embolism. It presents as a spontaneous extension of dissecting air without a history of a procedure or penetrating injury. Pulmonary air leak syndromes are extremely rare complications of systemic autoimmune connective tissue diseases. Few cases were reported in the literature regarding rheumatoid arthritis patients. The purpose of this article is to emphasize on this rare pulmonary complication and discuss the physiopathology of the disease and the different risk factors for a better management of these patients. We report the case of a 45-year-old female, with a history of proven rheumatoid arthritis under methotrexate and steroids, who presented with a spontaneous dissecting subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum. The patient’s condition improved after chest drainage and adjustment of her medical treatment.

Pneumomediastinum as a Manifestation of Granulomatosis with Polyangiitis

A 38-year-old hypertensive male with a smoking history presented to the emergency room with significant hemoptysis, arthritis, and a purpuric rash. Other findings included a dropping hemoglobin and acute kidney injury with microscopic hematuria. The pulmonary computed tomography was significant for alveolar hemorrhage and a rarely reported pneumomediastinum. Along with this constellation of findings, a positive antiproteinase 3 helped to confirm this patient's diagnosis of granulomatosis with polyangiitis. Treatment commenced with sessions of plasma exchange and pulse steroids along with cyclophosphamide infusions. The patient had since improved and made a full recovery. This case report highlights the rarely described pneumomediastinum in association with vasculitides.

Spontaneous Pneumomediastinum in Connective Tissue Diseases

BACKGROUND

Spontaneous pneumomediastinum (SP) is an uncommon disorder but has been described in cases with connective tissue diseases (CTDs), most commonly dermatomyositis and polymyositis. We aimed to explore this relationship by analyzing the characteristics of CTD patients with SP.

METHODS

Using a computer-assisted search, we identified 25 patients with CTD and SP evaluated between January 1997 and December 2016 at our institution. Clinicoradiologic characteristics, treatment, and outcomes were extracted and chest computed tomography studies analyzed.

RESULTS

We identified 25 patients with CTD and SP. Median (range) age at SP occurrence was 55 (18-82) years, and 60% of the patients were women. Smoking history was present in 37%. Spontaneous pneumomediastinum was symptomatic in 56% of patients. Eighteen patients (72%) had a known CTD diagnosis, and 20 patients (80%) manifested radiologic evidence of interstitial lung disease. Spontaneous pneumomediastinum diagnosis was achieved with chest radiography in 20% of cases and chest computed tomography in the other cases. Spontaneous pneumomediastinum was managed with expectant observation alone in 22 cases (88%). Four patients (16%) had concomitant pneumothorax, 1 of whom required chest tube drainage. There were no deaths attributable to SP during the median (range) follow-up of 13 (0-174) months. Cumulative survival was 52% at 1 year and 40% at 2 years.

CONCLUSIONS

Spontaneous pneumomediastinum is an uncommon manifestation of CTD and usually occurs in the presence of interstitial lung disease. Although SP seems to be associated with a relatively benign short-term course, occurrence of SP in CTD patients may be a poor prognostic factor.

Recurrent spontaneous subcutaneous emphysema in a patient with rheumatoid arthritis

Pulmonary air leak syndromes are extremely rare complications of systemic autoimmune connective tissue diseases and the occurrence of spontaneous subcutaneous emphysema (SSE) from pulmonary leak in the absence of pneumothorax or pneumomediastinum is even rarer. We report a case of recurrent SSE in a patient with rheumatoid arthritis and interstitial lung disease. The SSE was managed conservatively each time and it resorbed over several days. There has been no previous documented report of SSE in the absence of pneumomediastinum, pneumothorax or pulmonary nodules in a patient with RA.

Maraviroc: a review of its use in HIV infection and beyond

The human immunodeficiency virus-1 (HIV-1) enters target cells by binding its envelope glycoprotein gp120 to the CD4 receptor and/or coreceptors such as C-C chemokine receptor type 5 (CCR5; R5) and C-X-C chemokine receptor type 4 (CXCR4; X4), and R5-tropic viruses predominate during the early stages of infection. CCR5 antagonists bind to CCR5 to prevent viral entry. Maraviroc (MVC) is the only CCR5 antagonist currently approved by the United States Food and Drug Administration, the European Commission, Health Canada, and several other countries for the treatment of patients infected with R5-tropic HIV-1. MVC has been shown to be effective at inhibiting HIV-1 entry into cells and is well tolerated. With expanding MVC use by HIV-1-infected humans, different clinical outcomes post-approval have been observed with MVC monotherapy or combination therapy with other antiretroviral drugs, with MVC use in humans infected with dual-R5- and X4-tropic HIV-1, infected with different HIV-1 genotype or infected with HIV-2. This review discuss the role of CCR5 in HIV-1 infection, the development of the CCR5 antagonist MVC, its pharmacokinetics, pharmacodynamics, drug-drug interactions, and the implications of these interactions on treatment outcomes, including viral mutations and drug resistance, and the mechanisms associated with the development of resistance to MVC. This review also discusses available studies investigating the use of MVC in the treatment of other diseases such as cancer, graft-versus-host disease, and inflammatory diseases.

Spontaneous Tracheal Rupture in a Case of Interstitial Lung Disease (ILD): A Case Report

Spontaneous tracheal rupture is one of the rare life threatening conditions. Tracheal lacerations are generally secondary to cervical or chest trauma or occurring as a complication of endotracheal intubation. Only two cases of spontaneous tracheal rupture are reported, in adults, one due to acquired tracheobronchomalacia and other due to long term steroid use. We hereby report a very rare case of spontaneous tracheal rupture in young male patient of interstitial lung disease (ILD) who was on steroids for two months and developed spontaneous subcutaneous emphysema and pneumomediastinum. Tracheal rupture was diagnosed on unenhanced computed tomography (CT) and reconstructed virtual bronchoscopic images. Patient subsequently died due to cardiac arrest.

Pneumomediastinum in blunt chest trauma: a case report and review of the literature

Blunt trauma is the most common mechanism of injury in patients with pneumomediastinum and may occur in up to 10% of patients with severe blunt thoracic and cervical trauma. In this case report we present a 24-year-old man with pneumomediastinum due to blunt chest trauma after jumping from a bridge into a river. He complained of persistent retrosternal pain with exacerbation during deep inspiration. Physical examination showed only a slight tenderness of the sternum and the extended Focused Assessment with Sonography for Trauma (e-FAST) was normal. Pneumomediastinum was suspected by chest X-ray and confirmed by computed tomography, which showed a lung contusion as probable cause of the pneumomediastinum due to the "Mackling effect." Sonographic findings consistent with pneumomediastinum, like the "air gap" sign, are helpful for quick bedside diagnosis, but the diagnostic criteria are not yet as well established as for pneumothorax. This present case shows that despite minimal findings in physical examination and a normal e-FAST a pneumomediastinum is still possible in a patient with chest pain after blunt chest trauma. Therefore, pneumomediastinum should always be considered to prevent missing major aerodigestive injuries, which can be associated with a high mortality rate.

Pneumothorax and asthma

This review is focused on the relationship between asthma, pneumothorax and pneumomediastinum while presenting a number of case reports that include these conditions. The association between pneumothorax and asthma is not widely known. While asthma includes a common disorder and is prevalent worldwide, its morbidity and mortality is high when is associated with pneumothorax. Furthermore, the delayed diagnosis of pneumothorax while focusing on asthma includes the higher risk of coincidental pneumothorax in asthmatic patients. In addition, pneumomediastinum is considered benign and self-limiting condition that responds to conservative therapy. Although it is rare, the concurrence of pneumomediastinum with pneumothorax may prove fatal during a serious asthma attack. In conclusion, the symptoms of chest pain, dyspnea or focal chest findings when presented in asthmatic patients, must always create suspicion of pneumothorax or pneumomediastinum to the physician.

Spontaneous pneumomediastinum presenting as rhinolalia and chest pain

This report discusses a case of spontaneous pneumomediastinum in a 25-year-old medical student. The patient presented with chest pain and a tonal change in voice. Symptoms occurred after an episode of stretching and were exacerbated by coughing. There was no history of underlying respiratory disease and he was a non-smoker. Management was conservative. At the four-week follow-up appointment, bronchoscopy and computed tomography of the thorax demonstrated complete resolution. Spontaneous pneumomediastinum is uncommon, with rhinolalia being a rare presenting feature. It should be considered as a differential diagnosis in patients with chest pain associated with a change in voice. A detailed history may reveal preceding activities associated with raised intrathoracic pressure.

Spontaneous pneumomediastinum presenting as rhinolalia and chest pain

This report discusses a case of spontaneous pneumomediastinum in a 25-year-old medical student. The patient presented with chest pain and a tonal change in voice. Symptoms occurred after an episode of stretching and were exacerbated by coughing. There was no history of underlying respiratory disease and he was a non-smoker. Management was conservative. At the four-week follow-up appointment, bronchoscopy and computed tomography of the thorax demonstrated complete resolution. Spontaneous pneumomediastinum is uncommon, with rhinolalia being a rare presenting feature. It should be considered as a differential diagnosis in patients with chest pain associated with a change in voice. A detailed history may reveal preceding activities associated with raised intrathoracic pressure.

Pneumorrhachis and pneumomediastinum in connective tissue disease-related interstitial lung disease: case series from a tertiary care teaching hospital in South India

Pneumomediastinum has been described as a rare complication of connective tissue diseases. Here, we report four cases of pneumomediastinum: three of which are associated with dermatomyositis and one with mixed connective tissue disease. All our patients had interstitial lung disease. The first case of dermatomyositis described below was complicated by epidural emphysema (pneumorrhachis) in addition to pneumomediastinum. Pneumorrhachis is reported in many isolated case reports and series in the setting of asthma, pneumothorax, blunt chest trauma, etc. Less than 10% of pneumomediastinum cases develop this complication and vast majority of cases resolve spontaneously. The mechanism behind this has been postulated to be the passage of air through the intervertebral foramen. Others suggest entrapment of air which dissects between paraspinal soft tissues and along the vascular and nerve sheaths into the epidural space. This is the first ever reported case of epidural emphysema in connective tissue disease to the best of our knowledge.

Spontaneous pneumomediastinum and subcutaneous emphysema in systemic lupus erythematosus

We report a case of a 29-year-old woman who is known to have systemic lupus erythematosus and idiopathic interstitial pneumonia; she presented with a 1-day history of substernal chest pain and increasing shortness of breath. On examination, she was found breathless, but was not distressed or afebrile or normotensive. Auscultation of the heart revealed a positive Hamman's sign. There was chest-wall crepitus, and auscultation of the lung showed bilateral crepitations. Full blood count and biochemical profile were unremarkable. Chest x-ray showed signs of idiopathic interstitial pneumonia in addition to pneumomediastinum (linear band of air within mediastinal planes and continuous diaphragm sign) and chest-wall subcutaneous emphysema. She was treated with high-concentration oxygen. A repeat chest x-ray 5 days later showed complete resolution of the pneumomediastinum and subcutaneous emphysema, but signs of idiopathic interstitial pneumonia continued to persist.

Spontaneous pneumomediastinum: analysis of 62 consecutive adult patients

OBJECTIVE

To clarify the clinical presentation and course of patients with spontaneous pneumomediastinum (SP) and to determine the usefulness of diagnostic testing in these patients.

PATIENTS AND METHODS

We conducted a retrospective review of 62 consecutive adult patients (age >or=18 years) diagnosed as having SP during an 11-year period from July 1, 1997, to June 30, 2008. The study cohort included 41 men and 21 women (median age, 30 years; interquartile range, 20-69 years).

RESULTS

Among the 62 study patients, the most common presenting symptoms were chest pain (39 patients [63%]), cough (28 [45%]), and dyspnea (27 [44%]). Preexisting lung diseases were identified in 27 patients (44%) and included interstitial lung disease, asthma, lung malignancies, bronchiolitis obliterans syndrome, chronic obstructive pulmonary disease, bronchiectasis, and cystic lung lesions. The initial diagnosis of SP was achieved by chest radiography in 52 patients (84%); the remaining cases were diagnosed by computed tomography. Forty-seven patients (76%) were hospitalized for a median duration of 2.5 days. Additional diagnostic procedures were performed in 27 patients (44%) and included contrast esophagography, bronchoscopy, and esophagogastroduodenoscopy; however, they did not yield a pathologic cause in any patient. Pneumothorax was identified in 20 patients (32%), but less than one-third of these patients underwent chest tube thoracostomy. No episodes of mediastinitis or sepsis occurred. Recurrence of SP was seen in 1 patient, and thoracoscopic surgery was performed in 1 patient for persistent air leak (pneumothorax).

CONCLUSION

Spontaneous pneumomediastinum was associated with a relatively benign clinical course; however, pneumothorax was seen in 32% of cases. Diagnostic testing to determine a pathologic cause yielded little clinically relevant information in these patients.

Two case reports of pneumomediastinum

BACKGROUND

We present two cases of pneumomediastinum in patients who presented to the accident and emergency department of a large teaching hospital. One case had a history of inhalational drug abuse, which may have contributed to the event, while the other had no obvious precipitating factors.

AIMS

To evaluate the presenting symptoms, physical signs, diagnosis and management of pneumomediastinum with a review of the literature.

METHODS

We describe two cases of pneumomediastinum with a literature review.

CONCLUSIONS

Pneumomediastinum is an uncommon entity, first described almost 400 years ago. It presents with relatively non-specific symptoms and signs and will require radiological investigations to clarify the diagnosis. Treatment is conservative but will require close observation for the development of complications and occult visceral perforation. Complete resolution can be expected.

Spontaneous pneumomediastinum in a patient with recent air travel

Spontaneous pneumomediastinum (SPM) is a fairly uncommon condition in which free air is present in the mediastinum, often in young patients without injury or serious underlying pulmonary disease. We present a case of SPM in a 36-year-old man with no pertinent medical history who presented with chest pain after a 3-h flight. To the best of our knowledge, this is the first known case in radiology literature of SPM caused by increased intra-alveolar pressure secondary to increased altitude.

Spontaneous pneumomediastinum: a benign curiosity or a significant problem?

OBJECTIVE

To identify the significance of spontaneous pneumomediastinum (SPM) and to optimize its management.

METHODS

A retrospective analysis was undertaken of all patients presenting with SPM over a 5-year period. Eighteen patients were identified, and information on their presentations, initial diagnoses, comorbidities, investigations, clinical courses, length of hospital stays, and outcomes were collated.

SETTING

The emergency department referrals of two major Melbourne teaching hospitals.

RESULTS

SPM is an uncommon condition presenting in approximately 1 in 30,000 emergency department referrals. The typical patient identified from this study is a young man who is likely to have a history of asthma, and who is also likely to smoke or to use illicit drugs. The most common presentation is nonspecific pleuritic chest pain with dyspnea. Complications are rare, and the clinical course benign, but the possibility of a ruptured viscus or an initial misdiagnosis often leads to a great number of investigations. A proposed algorithm of management is given. Other serious and potentially life-threatening conditions, such as Boerhaave syndrome need to be excluded.

Pneumomédiastin compliquant un syndrome des anti-synthétases

INTRODUCTION

Pneumomediastinum is a rare but classical complication of dermatomyositis. Its development is a serious matter and necessitates prompt recourse to aggressive treatment with corticosteroids combined with immuno-suppressants or intravenous human immunoglobulin.

CASE REPORT

We report the case of a 63 year old woman presenting with pulmonary infiltration, in the presence of dermatomyositis, as a clinical manifestation of the anti-synthetase syndrome. The progress was rapidly unfavourable with pneumomediastinum and acute respiratory distress despite initial treatment with corticosteroids followed by human immunoglobulin and immunosuppressants.

CONCLUSION

The identification of cutaneous or muscular signs in the initial investigation of a pulmonary infiltrate should lead to a search for anti-synthetase antibodies in order to determine the optimal clinical management as quickly as possible.

Sports-related spontaneous pneumomediastinum

BACKGROUND

Spontaneous pneumomediastinum is a rare medical entity occurring almost exclusively in otherwise healthy young individuals without known predisposing factors. We reported our experience with patients presenting with spontaneous pneumomediastinum related to sports.

METHODS

Between January 1991 and December 2002, 10 patients were admitted with spontaneous pneumomediastinum related to sporting activities. We retrospectively reviewed their medical records with regard to predisposing factors, clinical presentation, diagnostic evaluation, and outcome.

RESULTS

The mean age of our patients was 18.9 years (range 15 to 25 years). Retrosternal chest pain was the most common symptom (90%), and subcutaneous emphysema the most common physical finding (90%). Hamman's sign was present in 9 patients. In all 10 patients, physical exertion during sports was the only implicating factor (scuba diving in 4 patients, basketball in 2, soccer in 3, and volleyball in 1). All patients were treated conservatively. Complete resorption of the pneumomediastinum occurred in 3 to 8 days. Hospital stay ranged from 2 to 6 days (mean 3.8 days). Follow-up was complete in 8 patients (80%), and ranged from 6 to 84 months (mean 35 months). Only 1 recurrence of pneumomediastinum was found that was treated similarly.

CONCLUSIONS

Spontaneous pneumomediastinum after sporting activities is a benign disease that generally resolves without clinical sequelae. Restriction of physical and athletic activity after the first episode is unnecessary, the only exception being that of scuba diving.

Thin-section CT assessment of spontaneous pneumomediastinum in interstitial lung disease: correlation with serial changes in lung parenchymal abnormalities

PURPOSE

The purpose of this study was to analyze thin-section computed tomography (CT) appearances of interstitial lung diseases before and at the time of detection of pneumomediastinum, and to evaluate the relationship between pneumomediastinum and parenchymal changes on thin-section CT.

MATERIALS & METHODS

We reviewed CT images before and at the time of detection of pneumomediastinum in 13 patients with idiopathic pulmonary fibrosis (8 patients) and collagen vascular diseases (5 patient). The extent of the total area of reticular opacity, increased opacity (ground-glass opacity and consolidation), and honeycombing were scored, and these scores were compared before and at the time of detection of pneumomediastinum. We also divided patients into two groups according to therapy received. Patients in group 1 experienced pneumomediastinum after or during treatment with corticosteroids or immunosuppressive agents for acute or subacute exacerbation of interstitial lung disease. Patients in group 2 experienced pneumomediastinum without therapy.

RESULTS

The mean score of all patients for honeycombing significantly increased at the time of detection of pneumomediastinum (P=0.003). In group 1, the extent of increasing opacity had been decreased significantly at the time of detection of pneumomediastinum (P=0.028). In group 2, the mean CT score of reticular opacity, increasing opacity, and honeycombing significantly increased at the time of detection of pneumomediastinum (P=0.028, 0.018, and 0.018, respectively).

CONCLUSIONS

Spontaneous pneumomediastinum associated with interstitial lung disease appears to have a tendency to occur under conditions of altered of parenchymal interstitial lesions.

[Subcutaneous emphysema as a complication of tooth extraction]

Subcutaneous emphysema is a rare complication in dentistry, which may lead to diagnostic errors and inadequate therapy. A 17 year old female patient, in whom the separation of tooth roots was performed by the use of air-powered drill during the extraction of the first right lower molar, is presented in this paper. During the intervention, swelling of the right half of the face and the lower eyelid suddenly occurred, accompanied with simultaneous feeling of choking, and pressure in the neck and chest. Because of the suspicion of the allergic reaction, the patient was administered antihistaminic agent, together with parenteral corticosteroid, and was sent to an institution where she was treated as an in-patient. During hospitalization, subcutaneous emphysema of the face and neck was diagnosed by physical and x-ray examination. The emphysema completely disappeared after the use of oxygen and antibiotics.

Spontaneous pneumomediastinum presenting with retropharyngeal emphysema

Spontaneous pneumomediastinum is a rare condition that may follow increases in intrathoracic pressure. Patients may present with symptoms isolated to the head and neck. Although this condition is usually benign, there are other potentially fatal conditions, which often present similarly and clinically are difficult to differentiate from this entity. Despite this condition being described in the thoracic and medical literature, very little is found in the otolaryngological literature. This article reports 4 cases in which presenting symptoms were limited to the head and neck and otolaryngologists were the initial consultants. This highlights the need for otolaryngologists to be aware of this clinical entity.

Bronchiolitis obliterans in a case of juvenile rheumatoid arthritis presented with pneumomediastinum

We present a case of bronchiolitis obliterans associated with juvenile rheumatoid arthritis in whom pneumomediastinum was the presenting manifestation. Diagnosis of bronchiolitis obliterans was made on the basis of the clinical history, pulmonary function tests and high-resolution computerized tomography scan findings. Pneumomediastinum resolved in a few days following high-dose nasal oxygen. This case shows that bronchiolitis obliterans can occur in patients with juvenile rheumatoid arthritis. Complicating pneumomediastinum in such cases should be considered as an indication of underlying bronchiolitis obliterans.

Pneumorachis and pneumomediastinum caused by repeated Müller's maneuvers: complications of marijuana smoking

Pneumomediastinum may occur during marijuana inhalation but only rarely has pneumorachis (epidural pneumatosis or aerorachia) been reported. The usual mechanisms that produce pneumomediastinum include severe acute asthma, toxic-induced bronchial hyperreactivity, and barotrauma caused by Valsalva's maneuver (expiration through resistance). We report a case in which barotrauma resulted from repeated deep inspiration through a device with airflow resistance equivalent to Müller's maneuver. Inspiration occurred through a homemade apparatus resembling a narrow outlet bong with 2 piled compartments. Pneumomediastinum combined with subcutaneous emphysema and pneumorachis occurred, without identified pneumothorax. There were no neurologic complications. Because of the absence of bronchospasm, expiration either through the apparatus or actively against a closed glottis, or apnea, this phenomenon is likely a result of repeated Müller's maneuvers. Successive inhalation through resistance could have resulted in extreme negative intrathoracic pressure, which would have caused a transmural pressure gradient inducing barotrauma and release of extrarespiratory air. High-concentration oxygen therapy to achieve nitrogen washout was used.