Spontaneous pneumopericardium in acute asthma: case report and review of the literature

Pneumothorax leading to pneumopericardium after transvenous lead implantation in a patient with previous epicardial lead

A 44-year-old lady, a follow-up case of idiopathic dilated cardiomyopathy and cardiac resynchronization therapy defibrillator device implantation with epicardial left ventricular (LV) lead, underwent a transvenous LV lead revision in view of epicardial lead malfunction. A chest X-ray after this, done for worsening dyspnea, revealed pneumopericardium along with left pneumothorax. The computed tomography (CT) revealed a communication between the left pleural and pericardial cavities, around the old epicardial lead. Drainage of the left pleural cavity resolved both the pneumothorax and pneumopericardium and the patient remained well on follow up.

Nontraumatic tension pneumopericardium in nonventilated pediatric patients: a review

BACKGROUND AND AIMS

Pneumopericardium is a rare air leak syndrome caused by the abnormal presence of air in the pericardial sac, with a high risk of morbidity and mortality. It is clinically divided into nontension and tension pneumopericardium, with the latter resulting in a decreased cardiac output and circulatory failure. There are limited data regarding nontraumatic pneumopericardium in nonventilated pediatric patients. Therefore, we aimed to describe a case of tension pneumopericardium and review the available literature.

METHODS

Case report and literature review of nontraumatic pneumopericardium in nonventilated pediatric patients.

RESULTS

A 2-month-old infant developed cardiac tamponade secondary to tension pneumopericardium 11 days after cardiac surgery promptly resolved with pericardium drainage. We reviewed the literature on this topic and retrieved 50 cases, of which 72% were nontension whereas a minority were tension pneumopericardium (28%). Patients with tension pneumopericardium were mostly neonates (35.7% vs 22.2%), presented with an isolated air leak (64.3% vs 36.1%), and had a history of surgery (28.6% vs 8.3%) or hematological disease (28.6% vs 11.1%). In all nontension cases, treatment was conservative, whilst in all other cases, pericardiocentesis/pericardium drainage was carried out. There was a high survival rate (86.0%), which was lower in patients with tension pneumopericardium (71.4% vs 91.6%).

CONCLUSIONS

Pneumopericardium is a rare condition with a higher mortality rate in patients with tension pneumopericardium, which requires immediate diagnosis and treatment. In nonventilated patients, tension pneumopericardium occurred more frequently in neonates, as an isolated air leak, and in those with a history of surgery or hematological disease.

Tension Pneumopericardium after Pericardiocentesis

Pneumopericardium is defined as the presence of air inside the pericardial space. Usually, it is reported as a complication of blunt or penetrating chest trauma, but rare iatrogenic and spontaneous cases have been reported. Pneumopericardium is relatively stable if it does not generate a tension effect on the heart. However, it may progress to tension pneumopericardium, which requires immediate pericardial aspiration. We report a case of iatrogenic pneumopericardium occurred in a 70-year-old man who presented dyspnea at emergency department. The patient underwent pericardiocentesis for cardiac tamponade due to large pericardial effusion, and iatrogenic tension pneumopericardium occurred due to misuse of the drainage device. After evacuating the pericardial air through the previously implanted catheter, the patient became stable. We report this case to increase the awareness of this fatal condition and to help increase the use of precautions against the development of this condition during emergency procedures.

Tracheal injury leading to tension pneumopericardium in a blunt trauma victim

Tracheal injury is uncommon in blunt thoracic trauma which may lead to subcutaneous emphysema and pneumomediastinum but rarely does it lead to tension pneumopericardium. We present a case of a 75-year-old female involved in a motor vehicle collision leading to multiple injuries including a tracheal injury associated with tension pneumopericardium seen on computed tomography. The patient underwent a pericardial window for decompression of her cardiac tamponade.

[Bronchopericardial fistula treatment by a metallic stent]

INTRODUCTION

Bronchopericardial fistula is a rare condition leading to pneumopericardium. This medical condition is often related to neoplastic disease, or a complication of surgical interventions. The treatment approach depends on both the etiology and the clinical presentation. In stable patients, pericardial drain insertion and/or surgical resection of the fistula are considered options for persistent cases. We present the case of a bronchopericardial fistula treated by placement of an endobronchial stent.

CASE PRESENTATION

A 64-year-old man operated on for lung cancer had a recurrence treated with radiation and chemotherapy. A pneumopericadium was discovered when he presented with a new onset of atrial fibrillation. Bronchoscopy revealed a fistula tract. Pericardial drainage was persistent and did not improve the clinical situation. The poor health status of the patient contraindicated surgery and an alternative therapeutic approach with endobronchial stent placement was undertaken. The fistula sealed immediately, the pericardial drain could be removed removed and the patient was able to be discharged from hospital.

CONCLUSION

Endobronchial stenting should be considered as a potential treatment option in patients with pneumopericardium secondary to bronchopericadial fistula, particularly where a non-surgical is required.

Pneumomediastinum and pneumopericardium in an 11-year-old rugby player: a case report

OBJECTIVE

Pneumomediastinum and pneumopericardium are rare occurrences in young athletes, but they can result in potentially life-threatening consequences.

BACKGROUND

While involved in a rugby match, an 11-year-old boy received a chest compression by 3 players during a tackle. He continued to play, but 2 hours later, he developed sharp retrosternal chest pain. A chest radiograph and an echocardiograph at the nearest emergency department showed pneumopericardium and pneumomediastinum.

DIFFERENTIAL DIAGNOSIS

Sternal and rib contusions, rib fractures, heartburn, acute asthma exacerbation, pneumomediastinum, pneumopericardium, pneumothorax, traumatic tracheal rupture, myocardial infarction, and costochondritis (Tietze syndrome).

TREATMENT

Acetaminophen for pain control.

UNIQUENESS

To our knowledge, this is the only case in the international literature of the simultaneous occurrence of pneumomediastinum and pneumopericardium in a child as a consequence of blunt chest trauma during a rugby match.

CONCLUSIONS

Pneumomediastinum and pneumopericardium may be consequences of rugby blunt chest trauma. Symptoms can appear 1 to 2 hours later, and the conditions may result in serious complications. Immediate admission to the emergency department is required.

Spontaneous pneumopericardium due to exertion

We report the unique case of a patient with an idiopathic pneumopericardium due to heavy lifting and discuss Valsalva's maneuver as a rare cause in the pathogenesis of pneumopericardium. Our patient recovered without treatment and had no recurrence of pneumopericardium during follow-up. All physicians should be aware of pneumopericardium as a possible cause of chest pain, especially when no trauma is visible. Pneumopericardium may also be an occasional complication of pneumothorax and pneunomediastinum.

Continuous left hemidiaphragm sign revisited: a case of spontaneous pneumopericardium and literature review

In pneumopericardium, a rare but potentially life threatening differential diagnosis of chest pain with a broad variety of causes, rapid diagnosis and adequate treatment are crucial. In upright posteroanterior chest radiography, the apical limit of a radiolucent rim, outlining both the left ventricle and the right atrium, lies at the level of the pulmonary artery and ascending aorta, reflecting the anatomical limits of the pericardium. The band of gas surrounding the heart may outline the normally invisible parts of the diaphragm, producing the continuous left hemidiaphragm sign in an upright lateral chest radiograph. If haemodynamic conditions are stable, the underlying condition should be treated and the patient should be monitored closely. Acute haemodynamic deterioration should prompt rapid further investigation and cardiac tamponade must be actively ruled out. Spontaneous pneumopericardium in a 20 year old man is presented, and its pathophysiology described.

Concurrent pneumopericardium and pneumothorax complicating lung cancer: a case report

The coexistence of pneumothorax and pneumopericardium in patients with primary lung cancer is a very rare phenomenon. We report one such case, in which squamous cell carcinoma of the lung was complicated by pneumopericardium and pneumothorax. Several explanations of the mechanisms involved will be discussed.

Chest pain in a young girl

Images

Tension pneumopericardium following blunt injury

Pneumopericardium caused cardiac tamponade in a patient who was struck in the chest by a motor vehicle. Subxiphoid pericardial window and pericardial drainage successfully treated this condition. Diagnosis of this rare form of tamponade depends on clinical examination supported by chest radiographic findings.

Pneumopericardium—a life-threatening complication of central venous catheterisation

A case of central venous catheterisation which was complicated by pneumoperi-cardium is presented. The clinical manifestations and management are described. Haemodynamic stability in this patient could not be achieved by conservative therapy and pericardiocentesis was necessary to save the patient.

Pneumopericardium following blunt chest injury: report of three cases

Three cases of pneumopericardium following blunt chest injury are presented. All three patients were victims of road traffic accidents and were managed at the University College Hospital, Ibadan, Nigeria. One of the patients had a tension pneumopericardium, which was relieved by pericardiocentesis. The other two patients had only small amounts of pericardial air, which was absorbed after about 1 week. All three patients had multiple chest and associated injuries. The suspected mechanism of the pneumopericardium in the three patients is pleuropericardial rupture in the presence of an intrathoracic air leak. This is the first report of pneumopericardium following blunt injury of the chest in Nigeria. Only 16 previous cases have been reported in the world literature.

Pneumopericardium after pneumonectomy and lobectomy

Pneumopericardium is a rare condition, most frequently reported in connection with prolonged artificial ventilation in infants with hyaline membrane disease. No reports of pneumopericardium after pulmonary surgery have been published. Two cases of pneumopericardium are reported, one of tension pneumopericardium after pneumonectomy and artificial ventilation and one that followed radical lobectomy and artificial ventilation. The radiographic findings included pneumopericardium and subcutaneous emphysema and the patient who had had a pneumonectomy had severe symptoms of cardiac tamponade. Prolonged artificial ventilation in patients after pulmonary surgery and in the presence of an intrathoracic air leak may be a hazard. The importance of prompt surgical intervention in cases of tension pneumopericardium is underlined; the treatment of choice is thoracotomy with pericardiotomy.

Tension pneumopericardium following blunt chest trauma

A 12-year-old victim of an automobile-pedestrian accident appeared to develop severely compromised cardiac output shortly after intubation and positive pressure ventilation. Anteroposterior and lateral chest films showed air within the pericardial sac. After pericardiocentesis and withdrawal of air, cardiac function improved markedly as evidenced by a rise in blood pressure and a slowing of the pulse. A catheter was left in the pericardial sac for several days. The patient remained hemodynamically stable throughout the hospital stay and was subsequently discharged. Documentation of this degree of tamponade from air in the pericardium is quite uncommon.

Traumatic tension pneumopericardium: a case report and literature review

A 39-year-old male arrived in the emergency department with multiple stab wounds to the chest. A pneumopericardium was present on initial chest x-ray study. He subsequently developed hypotension, tachycardia, an elevated CVP (36 cm H2O) and a pulsus paradoxus. All parameters improved following removal of 100 cc of air by pericardiocentesis. The etiology, diagnosis, pathophysiology, and treatment of tension pneumopericardium are discussed.

Pneumopericardium resulting in cardiac tamponade

Cardiac tamponade most commonly results from accumulation of blood or other fluids within the pericardial sac. However, there is a growing body of clinical evidence showing that pneumopericardium can lead to cardiac tamponade in a large number of patients. Including those in the present report, a total of 252 patients with pneumopericardium are available for review. Interestingly, cardiac tamponade developed in 94 patients, or 37% of this group, because of air within the pericardial space. Pneumopericardium resulting in tamponade most frequently occurs in trauma patients or in newborn infants requiring positive pressure ventilation. This syndrome can be recognized promptly because of its characteristic physical findings and radiographic features. Although air tamponade can be treated effectively by either needle aspiration or insertion of a pericardial tube, the development of a pneumopericardium is a bad prognostic sign. Out of the 221 patients reported in the literature whose outcome is known, 127 (57%) died. In the group with a tension pneumopericardium, the mortality was 56% (53 out of 94 patients). Even without the development of tension, however, pneumopericardium was associated with a 58% mortality (74 out of 127 patients) due to other underlying disease processes.

Pneumopericardium and pneumomediastinum following closed chest injury

Pneumopericardium and pneumomediastinum following closed chest injury are rare findings, especially when symptoms are delayed for several days and are not associated with other related traumatic entities. A case is presented of a 14-year-old boy who developed symptoms of precordial chest pains and splinting two days after sustaining a direct blow to his anterior chest wall. A work-up confirmed free air in the pericardium and mediastinum. He recovered rapidly after a three-day hospital course. The diagnosis was relatively simple, using only thorough physical examination and radiographic technique. This complication should be considered in the differential diagnosis of sudden onset of cardiorespiratory conditions following trauma.

Pneumopericardium as a complication of foreign body aspiration

A case of pneumopericardium in an infant complicating aspiration of a foreign body is reported. In addition to X-ray studies echocardiography is valuable for the control of the disease. The pathogenesis and the treatment are discussed and a short review of the literature is given.

Fatal tension pneumopericardium complicating tracheostomy

The findings in a patient who developed a fatal pneumopericardium following tracheostomy are reported. This complication of tracheostomy does not appear to have been reported previously in the literature.. When recognized, pneumopericardium is a treatable lesion, and clinicians should be aware of this potential complication.

Penumopericardium and tension pneumopericardium after closed-chest injury

Three recent cases of pneumopericardium after closed-chest injury are described. The mechanism of pericardial inflation suspected in each was pleuropericardial laceration in the presence of an intrathoracic air leak. Deflation of the pericardium was achieved by underwater seal drainage of the right pleural cavity in the first patient, during thoracotomy for repair of tracheobronchial rupture in the second, and by subxiphoid pericardiotomy in the last. Haemodynamic changes after escape of air from the periion pneumopericardium and air tamponade.

Pneumopericardium associated with bronchogenic carcinoma

A case of pneumopericardium associated with primary bronchogenic carcinoma is reported. This association between bronchogenic carcinoma and pneumopericardium has not been reported. The roentgenographic features of pneumopericardium are discussed.