Spontaneous pneumomediastinum: experience in 18 patients during the last 12 years

Computed tomography imaging-guided parasternal approach drainage for children with tension pneumomediastinum: a case series

PURPOSE

Tension pneumomediastinum is a rare and dangerous complication in children that can be fatal, and timely detection and treatment are critical. The aim of this study was to evaluate the safety and feasibility of computed tomography (CT) imaging-guided parasternal approach drainage for tension pneumomediastinum in children.

METHODS

From June 2018 to February 2023, we consecutively enrolled 19 children with tension pneumomediastinum in our institution. A pigtail catheter was inserted into the anterior mediastinum by a CT imaging-guided parasternal approach. The catheter was connected to a negative-pressure water seal bottle to drain the pneumomediastinum. Clinical data and outcomes were summarized.

RESULTS

The mean age was 3.1 ± 3.4 years, the mean weight was 15 ± 9.1 kg, the mean procedure time was 11.8 ± 2.4 min, and the drainage time was 6.7 ± 3.4 days. No major complications were identified, such as haemothorax, catheter displacement, or mediastinal infection. Effective drainage was obtained in all patients as assessed by comparing images and ventilatory parameters, and no additional surgical treatment was needed. There was no recurrence during the follow-up, which was more than 2 months. In our data, two children with COVID-19 were discharged from the hospital after effective drainage and other clinical treatment.

CONCLUSION

CT-guided parasternal approach drainage is safe, minimally invasive, and effective for children with tension pneumomediastinum.

Pneumomediastinum in COVID-19 disease: Clinical review with emphasis on emergency management

Pneumomediastinum can be primary (spontaneous) or secondary to iatrogenic, traumatic, and non-traumatic causes. The incidence of spontaneous and secondary pneumomediastinum is higher in patients with coronavirus disease 2019 (COVID-19) compared to the general population. So, pneumomediastinum should be considered in the differential diagnosis of any patient with COVID-19 presenting with chest pain and breathlessness. A high level of suspicion is required to diagnose this condition promptly. Unlike in other disease conditions, pneumomediastinum in COVID-19 has a complicated course with higher mortality in intubated patients. No guidelines exist for managing pneumomediastinum patients with COVID-19. Therefore, emergency physicians should be aware of the various treatment modalities besides conservative management for pneumomediastinum and life-saving interventions for tension pneumomediastinum.

Spontaneous pneumomediastinum in a young adult female

Spontaneous pneumomediastinum is characterized by the accumulation of air in the mediastinum with no identified cause. It is a rare and self-limiting condition. We report the case of a 32-year-old female patient with controlled bronchial asthma, who presented with spontaneous pneumomediastinum, with no precipitating event. The evolution is generally benign and the treatment is conservative. Symptomatic medication may be instituted.

[Pneumomediastinum and vomiting: Which approach to diagnosis? A case report]

BACKGROUND

Spontaneous pneumomediastinum (SPM) is a rare and often unrecognized condition of which vomiting is one of the reported triggering factors. Differentiating SPM from Boerhaave's syndrome (pneumomediastinum secondary to esophageal breach) is the first step in management and prognosis.

OBSERVATION

A 27-year-old woman with systemic lupus erythematous presented to the emergency department with epigastralgia, incoercible vomiting and diarrhoea. Abdominal CT showed circumferential thickening of the duodenum and bilateral ureteritis. Chest sections showed pneumomediastinum extending to the cervical region. Therapeutic management was based on prophylactic antibiotic therapy and an absolute diet (fasting). A CT scan with upper gastrointestinal opacification was performed to prevent esophageal rupture and showed quasi-obstructive thickening of the antral mucosa. The diagnosis was lupus enteritis and pneumomediastinum was secondary to the vomiting efforts. The patient was placed on corticosteroids and a favorable outcome ensued.

CONCLUSION

Strenuous vomiting is one of the precipitating factors of SPM. Boerhaave's syndrome is the main differential diagnosis with a poor prognosis, unlike SPM, which has a good prognosis with conservative treatment.

Spontaneous Pneumomediastinum, Pneumoperitoneum, and Subcutaneous Emphysema beyond the Inguinal Ligament Secondary to Inversion Maneuvers

Pneumomediastinum is free air within the mediastinal cavity which can spread along tissue planes leading to the accumulation of large amounts of subcutaneous emphysema. Patient is a 21-year-old male with a history of autism spectrum disorder and rhabdomyolysis who presented with diffuse “popping under the skin” and was found to have crepitus extending from his neck to his bilateral ankles. He exercises frequently and performs chin-up pullovers and will often hold his breath during this movements. He uses an inversion table but denies any valsalva maneuvers or straining while inverted. Radiological imaging demonstrated pneumomediastinum, pneumoperitoneum, and diffuse subcutaneous emphysema extending into the pelvis. Diagnosis requires a combination of history, physical exam findings, and imaging findings. Patients with spontaneous pneumomediastinum typically experience self-limited disease, and efforts should be made to minimize low yield invasive testing. Most patients can be treated on an outpatient basis after monitoring and education about potential complications.

Pneumomediastinum: retrospective analysis of 19 cases and an innovation proposal in classification

Background

Guidelines to standardize treatment and follow-up strategies in pneumomediastinum cases are lacking. The aim of the study was to evaluate the etiology in pneumomediastinum cases and the results of treatment and follow-up.

Results

Nineteen patients with pneumomediastinum who were followed up in our clinic between 2015 and 2020 comprised the study population. Among the patients, 16 (84.2%) were male, and the mean age was 31.15 years. The chief presenting complaints were chest pain and dyspnea. Pneumomediastinum was spontaneous in 15/19 patients (including spontaneous pneumomediastinum with an underlying pathology in 3/15), traumatic in 3/19, and iatrogenic in 1/19. Spontaneous pneumomediastinum without underlying pathology was seen in younger adults (mean age: 23 years). Surgical intervention in traumatic and iatrogenic pneumomediastinum cases was compared with spontaneous cases and no statistically significant difference was observed (p=0.178). The mean hospital stay of all patients was 3.15 days. Only one patient had a recurrence and died, which was later determined to be a secondary spontaneous pneumomediastinum case.

Conclusion

Pneumomediastinum often occurs with an underlying pathology in advancing age and as spontaneous in younger patients. Therefore, “secondary spontaneous pneumomediastinum” subclass should be evaluated in the classification to facilitate to create a standard guideline and prevent overdiagnosis and overtreatment.

Risk Factors, Characteristics, and Outcome in Non-Ventilated Patients with Spontaneous Pneumothorax or Pneumomediastinum Associated with SARS-CoV-2 Infection

Background and Objectives

Spontaneous pneumothorax (SP) and spontaneous pneumomediastinum (SPM) have frequently been cited as complications associated with coronavirus disease 2019 (COVID-19) pneumonia, with especially poor prognosis in mechanically ventilated patients. The current literature is controversial regarding the potential risk factors for developing SP or SPM (SP-SPM) in non-ventilated COVID-19 patients. Our research addressed a twofold objective: (a) to investigate the characteristics of patients with SP-SPM (both with and without COVID-19) and compare them to patients with sole COVID-19; (b) to quantify the risk of in-hospital mortality associated with SP-SPM and COVID-19.

Patients and Methods

A retrospective case–control study was conducted in the emergency departments (ED) of two tertiary hospitals in Timisoara, Romania, over one year (1st April 2020‒31st March 2021; 64,845 records in total) and 70 cases of SP-SPM were identified (both SARS-CoV-2 positives and negatives). The control group comprised COVID-19 patients with no SP-SPM, included at a 2:1 ratio. Logistic regression was employed to quantify the in-hospital mortality risk associated with age, SP-SPM, and COVID-19.

Results

SP-SPM and COVID-19 were connected with prolonged hospitalization, a higher percentage of intensive care admission, and a higher mortality. SP-SPM increased the odds of death by almost four times in patients of the same age, gender, smoking status, and SARS-CoV-2 infection: OR = 3.758, 95% CI (1.443–9.792). Each additional year of age added 9.4% to the mortality risk: OR = 1.094, 95% CI (1.054–1.135).

Conclusion

ED physicians should acknowledge these potential risks when attending COVID-19 patients with SP-SPM.

A case of spontaneous pneumomediastinum in a patient with severe SARS-CoV-2 and a review of the literature

Spontaneous pneumomediastinum is defined as having an etiology that is not related to surgery, trauma, or mechanical ventilation. Precipitating causes of spontaneous pneumomediastinum include coughing, exercise, vomiting, infection, underlying lung diseases such as asthma, and illicit drugs. Symptoms include chest pain, shortness of breath, and dysphagia. A 54-year-old man presented with 2 weeks of shortness of breath, cough, and fever. He was admitted for severe SARS-CoV-2 pneumonia and acute hypoxic respiratory failure requiring non-rebreather mask. Chest imaging on admission showed bilateral peripheral consolidations and pneumomediastinum with subcutaneous emphysema. No precipitating event was identified. He did not require initiation of positive pressure ventilation throughout his admission. On hospital day 7, chest imaging showed resolution of pneumomediastinum and subcutaneous emphysema, and he was successfully discharged on oxygen therapy. Spontaneous pneumomediastinum is a rare complication of severe acute respiratory syndrome coronavirus 2 infection. Spontaneous pneumomediastinum is typically benign and self-limiting, requiring only supportive treatment.

Pneumomediastinum in patients with SARS-CoV-2 treated with non-invasive ventilation

SARS-CoV-2, causing the pandemic COVID-19, has rapidly spread, overwhelming healthcare systems. Non-invasive positive pressure ventilation (NIV) can be used as a bridging therapy to delay invasive mechanical ventilation or as a standalone therapy. Spontaneous pneumomediastinum is rare and self-limiting, but there is an increased incidence documented in COVID-19.

Here we document two cases of pneumomediastinum-related prolonged NIV therapy in severe COVID-19. Patient 1, a 64-year-old man, who developed symptoms after NIV therapy was weaned and survived. Patient 2, an 82-year-old woman, failed to improve despite NIV therapy, on investigation was found to have a pneumomediastinum. After review, the patient was placed on best supportive care and died 3 days later.

We highlight the importance of recognising less common causes of deterioration in severe COVID-19 treated with NIV. In addition, pneumomediastinum in these cases may not always lead to poor outcomes.

Spontaneous Pneumomediastinum: Analysis of 11 Cases

Objectives:

The presence of free air in mediastinum is defined as pneumomediastinum. The incidence is between 1/7000-1/32000. In this study, our aim is to discuss our cases with spontaneous pneumomediastinum (SPM), which has low incidence, in the light of the literature.

Methods:

The files of 11 cases who were diagnosed with SPM in pulmonary diseases and thoracic surgery department and followed up and treated in thoracic surgery clinic between 2012-2018 were retrospectively analyzed. Patients’ age, sex, etiological factors, diagnosis and treatment methods and hospital stay were evaluated.

Results:

Between the years of 2012-2018, 11 cases with SPM who were not related to trauma were detected. Nine (81.8%) of the patients were male; the median age was 38.5 years. Among the predisposing factors that played a role in the formation of SPM, the most common symptom was dyspnea, while the second most common symptom was coughing seizures. The median duration of hospitalization was 3.8 days, and no mortality was observed.

Conclusion:

Spontaneous pneumomediastinum is a rare clinical condition, especially in young men. SPM treatment can be conservative or surgical.

Pediatric Spontaneous Pneumomediastinum after a Push-Up Exercise: An Uncommon Complication of a Common Exercise

Pediatric spontaneous pneumomediastinum is an uncommon condition associated with infection, trauma, or coexisting structural lung pathology. Exercise-related spontaneous subcutaneous emphysema and pneumomediastinum are rarely reported. However, severe pneumomediastinum may coexist with pneumothorax, pneumorrhachis, and subcutaneous emphysema, which can potentially lead to serious complications, including airway obstruction and pneumorrhachis. Therefore, early diagnosis and timely management are important for physicians to determine the etiology and prevent further damage. Here, we present a case of exercise-related spontaneous subcutaneous emphysema and pneumomediastinum to highlight the pathogenesis and suggest therapeutic strategies.

Spontaneous pneumomediastinum in H1N1 infection: uncommon complication of a common infection

H1N1 viral infection leads to complications, such as pneumonia, respiratory failure, myocarditis and encephalitis. Spontaneous pneumomediastinum (SPM) is an extremely rare consequence of H1N1 infection and such cases have been sparsely reported. SPM is identified only by a careful clinical examination and obtaining a timely roentgenogram. We report a case of a young male admitted with H1N1 infection complicated by pneumomediastinum. He was treated successfully with oseltamivir, high-flow oxygen and prompt care in the intensive care unit.

Left-sided Neck Swelling: An Unusual Presentation of a Rare Disease

Pneumomediastinum describes air infiltrating into the soft tissues of the mediastinum. It may be classified as spontaneous or secondary. Spontaneous pneumomediastinum is a rare disease, which usually resolves without intervention. The acute onset of chest pain is the most common presenting complaint.  This article presents a case of spontaneous pneumomediastinum in a 19-year-old man with a short history of rapidly enlarging, painless swelling to the left side of his neck, followed by a discussion of the literature. The diagnosis was made following chest x-ray (CXR) and computed tomography (CT). There was no history of any precipitating event or any risk factors. He was managed conservatively and discharged with outpatient follow-up.  Management of spontaneous pneumomediastinum continues to vary and may benefit from the development of guidelines to standardise management in the future.