Pneumomediastinum.

Pneumomediastinum, air within the mediastinum, is the manifestation of a variety of causes including those that are benign and some resulting in severe morbidity and even mortality. This article reviews the epidemiology, etiology, and pathophysiology of pneumomediastinum as an independent pathologic and physiologic entity, as well as reviews the workup and management of those patients who are diagnosed with pneumomediastinum.

Cervicofacial Subcutaneous Emphysema and Pneumomediastinum Following Class V Resin Restoration: A Case Report.

Air can become trapped within the subcutaneous layer of the cervicofacial area, a condition known as subcutaneous emphysema (SE), unexpectedly after routine dental procedures. SE can worsen by extending superiorly to the peri-orbital region and inferiorly to the thorax and abdomen along the fascial planes. Upward progression can result in cavernous sinus thrombosis. Conversely, downward progression can cause a variety of complications such as pneumothorax, mediastinitis, and compression of the venous trunks. The presence of these conditions highlights the significance of prompt identification, precise diagnosis to ascertain the need for immediate intervention, and suitable management to prevent additional unfavorable consequences.

Retrospective evaluation of traumatic pneumomediastinum in dogs and cats (2005-2022): 52 cases.

OBJECTIVE: To describe the incidence, etiology, clinical signs, diagnostics, treatments, and outcome of noniatrogenic traumatic pneumomediastinum (TPM) in dogs and cats. DESIGN: Retrospective study of cases (2005-2022). SETTING: University veterinary teaching hospital. ANIMALS: Fifty-two patients (29 dogs, 23 cats). MEASUREMENTS AND MAIN RESULTS: Data collected from the medical records included signalment, physical examination findings, animal trauma triage (ATT) score, clinicopathological data, imaging data, surgical intervention, length of hospitalization, supportive care, complications, and outcome. Most dogs presented with tachycardia and tachypnea, while cats presented with hypothermia and tachypnea. Subcutaneous emphysema, pneumothorax, and dyspnea were the most common clinical signs for both species. The median calculated ATT score was 3.5 in dogs and 4 in cats. The most common radiographic abnormalities other than pneumomediastinum were pneumothorax and lung contusions. The overall mortality rate was 18%, with a significantly higher survival rate in dogs (26/28 dogs [93%], 15/22 cats (68%); P = 0.03). Outcome was unknown in 1 dog and 1 cat. The only significant difference in treatment between survivors and nonsurvivors was the requirement in dogs for positive pressure ventilation. The median hospitalization period was 2 days for both species, with a shorter hospitalization in the nonsurvivors (0.6 vs 2 days, respectively; P = 0.006). CONCLUSIONS: TPM is an infrequent pathology in veterinary medicine and may be seen without an externally obvious injury. The most common causes for TPM in dogs were vehicular trauma and bite wounds, while high-rise syndrome was the most common cause in cats. Most of the cases have concurrent pneumothorax and require thoracocentesis; however, direct intervention to treat TPM is not usually required. The vast majority of cases did not undergo surgery to treat TPM. The prognosis for dogs with TPM was good but was guarded for cats.

Conservative Management of Large Post-Intubation Tracheal Laceration.

ABSTRACT: Tracheal rupture is a very rare but life-threatening complication of endotracheal intubation. It is more common in women and patients older than 50 years old. Overinflation of endotracheal tube cuff and tracheal wall weakening are the most important pathogenetic mechanisms. Laceration sites are located in the posterior membranous wall in most cases. Subcutaneous and mediastinal emphysema and respiratory distress are the most common manifestations. A 55-year-old female presented with postoperative subcutaneous and mediastinal emphysema without dyspnea because of a tear in the posterior tracheal wall. The diagnosis was based on clinical manifestation, chest computer tomography scans (CT), and endoscopic findings. A conservative approach by broad-spectrum antibiotic therapy was decided because of patients' vital signs stability and the absence of esophageal injury. The follow-up showed that there was no lesion in the posterior tracheal wall. Our case showed that in clinically stable patients without mediastinitis and with spontaneous breathing, conservative management of tracheal tears is a safe procedure.

Extracorporeal membrane oxygenation versus invasive ventilation in patients with COVID-19 acute respiratory distress syndrome and pneumomediastinum: A cohort trial.

BACKGROUND: Patients with severe respiratory failure due to COVID-19 who are not under mechanical ventilation may develop severe hypoxemia when complicated with spontaneous pneumomediastinum (PM). These patients may be harmed by invasive ventilation. Alternatively, veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) may be applied. We report on the efficacy of V-V ECMO and invasive ventilation as initial advanced respiratory support in patients with COVID-19 and acute respiratory failure due to spontaneous PM. METHODS: This was a retrospective cohort study performed between March 2020 and January 2022. Enrolled patients had COVID-19 and acute respiratory failure due to spontaneous PM and were not invasively ventilated. Patients were treated in the intensive care unit (ICU) with invasive ventilation (invasive ventilation group) or V-V ECMO support (V-V ECMO group) as the main therapeutic option. The primary outcomes were mortality and ICU discharge at 90 days after ICU admission. RESULTS: Twenty-two patients were included in this study (invasive ventilation group: 13 [59%]; V-V ECMO group: 9 [41%]). The V-V ECMO strategy was significantly associated with lower mortality (hazard ratio [HR] 0.33 [95% CI 0.12-0.97], p = 0.04). Five (38%) patients in the V-V ECMO group were intubated and eight (89%) patients in the invasive ventilation group required V-V ECMO support within 30 days from ICU admission. Three (33%) patients in the V-V ECMO group were discharged from ICU within 90 days compared to one (8%) patient in the invasive ventilation group (HR 4.71 [95% CI 0.48-45.3], p = 0.18). CONCLUSIONS: Preliminary data suggest that V-V ECMO without invasive ventilation may improve survival in COVID-19-related acute respiratory failure due to spontaneous PM. The study's retrospective design and limited sample size underscore the necessity for additional investigation and warrant caution.

Pneumoperitoneum, pneumoretroperitoneum and pneumomediastinum: rare complications of perforation peritonitis: a case report.

BACKGROUND: Gas extravasation complications arising from perforated diverticulitis are common but manifestations such as pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum happening at the same time are exceedingly rare. This case report explores the unique presentation of these 3 complications occurring simultaneously, their diagnosis and their management, emphasizing the importance of interdisciplinary collaboration for accurate diagnosis and effective management. CASE PRESENTATION: A 74-year-old North African female, with a medical history including hypertension, dyslipidemia, type 2 diabetes, goiter, prior cholecystectomy, and bilateral total knee replacement, presented with sudden-onset pelvic pain, chronic constipation, and rectal bleeding. Clinical examination revealed hemodynamic instability, hypoxemia, and diffuse tenderness. After appropriate fluid resuscitation with norepinephrine and saline serum, the patient was stable enough to undergo computed tomography scan. Emergency computed tomography scan confirmed perforated diverticulitis at the rectosigmoid junction, accompanied by the unprecedented presence of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum. The patient underwent prompt surgical intervention with colo-rectal resection and a Hartmann colostomy. The postoperative course was favorable, leading to discharge one week after admission. CONCLUSIONS: This case report highlights the clinical novelty of gas extravasation complications in perforated diverticulitis. The unique triad of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum in a 74-year-old female underscores the diagnostic challenges and the importance of advanced imaging techniques. The successful collaboration between radiologists and surgeons facilitated a timely and accurate diagnosis, enabling a minimally invasive surgical approach. This case contributes to the understanding of atypical presentations of diverticulitis and emphasizes the significance of interdisciplinary teamwork in managing such rare manifestations.

Management of Pediatric Patients With Spontaneous Pneumomediastinum: A Retrospective Chart Review.

PURPOSE: Given the paucity of data on pediatric spontaneous pneumomediastinum (SPM), management is largely informed by extrapolation from adult studies or personal clinical experience, resulting in significant heterogeneity. The purpose of this study was to describe how pediatric patients with SPM are clinically managed at our institution and propose a treatment algorithm. METHODS: Retrospective chart review of pediatric patients with SPM from April 2002 to December 2021 at a single Canadian tertiary care center. Data on medical history, presentation characteristics, clinical management, and complications were gathered. Descriptive and inferential statistics were used to analyze data. RESULTS: We identified 63 patients for inclusion, median age was 15 years. Twenty-nine patients were transferred from another facility. Most common presenting symptoms were chest pain (72.3%), shortness of breath (44.6%), and subcutaneous emphysema (21.5%). Initial workup included chest x-ray (93.6%), CT scan (20.6%), and upper GI series (7.9%). There was no difference in the number of initial tests between admitted and discharged patients (p = 0.10). Of admitted patients (n = 35), 31.4% had primary SPM (no underlying comorbidity/inciting event) and 68.8% were secondary SPM (underlying comorbidity/inciting event). No patients with primary SPM developed complications or recurrences. In contrast, 16.7% of those with secondary SPM developed complications and 54.2% had at least one additional intervention after admission. DISCUSSION: There is significant variability in diagnostic investigation and treatment of pediatric SPM at our center. Amongst primary SPM, additional tests did not change complication rate or recurrence, including those transferred from another facility. An expeditious treatment algorithm is warranted. TYPE OF STUDY: Retrospective Cohort Study. LEVEL OF EVIDENCE: III.

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.

Protracted Labor Complicated by Pneumomediastinum and Subcutaneous Emphysema: A Rare Case Report and Management Considerations.

BACKGROUND Spontaneous pneumomediastinum and subcutaneous emphysema (Hamman's syndrome) presents with sudden and life-threatening symptoms. Clinical signs include crackles that synchronize with the heartbeat on chest auscultation (Hamman's sign). This report describes the case of a 29-year-old woman with a protracted second stage of labor at 40 weeks of pregnancy with postpartum dyspnea, acute chest pain, and surgical emphysema due to pneumomediastinum (Hamman's syndrome). CASE REPORT This case report describes the case of a 29-year-old primigravida admitted to the hospital ward for spontaneous labor at 40 weeks of pregnancy. Due to a protracted second stage of labor, the delivery was assisted by Thierry's spatulas. Shortly after delivery, the patient developed dyspnea associated with subcutaneous emphysema in the inferior part of the face, neck, and anterior chest wall. As the clinical evaluation showed no signs of severity, we performed a chest X-ray, which confirmed the diagnosis of pneumomediastinum (Hamman's syndrome), excluded any other life-threatening condition, and led to a conservative treatment approach. CONCLUSIONS This report presents a rare association between protracted labor and Hamman's syndrome and highlights the importance of rapid diagnosis and management. In this case, the postpartum presentation was distinguished from pulmonary embolism, and emergency life-saving management was initiated.

A Case of a Highly Obese Covid-19 Patient with Severe Hypoxemia and Subcutaneous Mediastinal Emphysema Who Was Rescued by Early Introduction of ECMO.

We conducted the treatment of a highly obese patient with severe Covid-19 pneumonia who had a history of asthma. When she arrived at the hospital, she was already intubated and had mediastinal emphysema and severe hypoxemia. Because the patient's condition did not improve with mechanical ventilation, we introduced extracorporeal membrane oxygenation (ECMO) immediately after admission. The patient improved with early induction of ECMO and prone positioning. In the management of patients with severe Covid-19 pneumonia, early introduction of ECMO should be considered if oxygenation does not improve with mechanical ventilation, and prone positioning can also be effective.

Pneumothorax, pneumomediastinum, and subcutaneous emphysema in hospitalized COVID-19 patients: incidence, clinical characteristics, and outcomes.

BACKGROUND: Limited data is available on the incidence and outcomes of pneumothorax (PTX), pneumomediastinum (PNM), and subcutaneous emphysema (SCE) in COVID-19 patients. This study aimed to investigate the characteristics of these complications in hospitalized COVID-19 patients. RESEARCH DESIGN AND METHODS: A retrospective study was conducted, involving adult COVID-19 patients admitted to Mayo Clinic Florida from 03/2020-06/2022. Patients were divided into two groups based on the presence or absence of PTX/PNM/SCE. RESULTS: 1926 hospitalized patients with COVID-19 were included, of which 518 were admitted to the ICU. The incidence of PTX/PNM/SCE was 6.3%. Patients with these complications were more likely to be male, Asian, and unvaccinated. Conversely, they were less likely to have chronic obstructive pulmonary disease. Patients who developed PTX/PNM/SCE after 72 hours of admission were more likely to receive high-dose corticosteroids and for an extended duration. The affected group had an adjusted odds ratio for in-hospital mortality of 13.32 (95%CI, 8.19-21.59) and ICU admission of 9.14 (95%CI, 5.3-12.78) compared to the unaffected group. CONCLUSION: Although the occurrence of PTX/PNM/SCE in hospitalized COVID-19 patients was rare, it was associated with worse outcomes. Corticosteroids may contribute to the pathogenesis of these complications; however, further studies are needed to investigate this relationship in more detail.

Conservative Approach For The Management Of Bilateral Pneumothorax And Pneumomediastinum After Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair.

Laparoscopic totally extraperitoneal inguinal hernia repair is considered a common and safe procedure. Here, we present the case of a 31-year-old male with right indirect inguinal hernia and no medical history. The patient underwent laparoscopic totally extraperitoneal inguinal hernia repair and the operation was completed successfully. During extubation, subcutaneous emphysema was noted at the neck, chest, and above the nipples. Tracheal injury was excluded by the anaesthesiologists and otorhinolaryngologists. On arterial blood gas, the patient's oxygen saturation was 95% with nasal oxygen support. The patient was followed-up closely in the general surgery inpatient clinic. Computed tomography was performed, on which bilateral pneumothorax and pneumomediastinum were noted. Conservative management was planned and the patient was discharged on the fourth postoperative day. Laparoscopic totally extraperitoneal inguinal hernia repair is considered a routinely applied safe procedure, however, appropriate care should be taken to avoid possible complications.

Pneumoperitoneum, pneumomediastinum and subcutaneous emphysema following argon plasma coagulation treatment of colonic angioectasia.

INTRODUCTION: The paper presents unusual symptoms as a complication of therapeutic colonoscopy. CASE REPORT: A 70-year-old polymorbid female patient in chronic dialysis program underwent argon plasma coagulation treatment of leaking angioectasias in the cecum and ascending colon. Shortly after the procedure she presented with shortness of breath and subcutaneous emphysema of the neck which was initially misdiagnosed as swelling. Further tests revealed pneumoperitoneum, subcutaneous emphysema and pneumomediastinum. Considering the high risks for our patient (comorbidities, obesity), a laparoscopic approach was indicated. During laparoscopy neither peritonitis nor intestinal perforation were found. The patient recovered without complications after further complex treatment. CONCLUSION: Shortness of breath and subcutaneous emphysema are not typically among the first symptoms of colonoscopic perforation. Our case confirms that we should bear this complication in mind and when suspected, the diagnostic process should be started without delay.

Pneumorrhachis with spontaneous pneumomediastinum in pediatric patients: An 11-year retrospective study in Southern Taiwan.

BACKGROUND: Although uncommon, available evidence suggests that pneumorrhachis (PR) with spontaneous pneumomediastinum (SPM) in adulthood is usually benign and self-limiting. This study aimed to review our experience and identify the risk factors of PR in pediatric patients with SPM. METHODS: Between September 2007 and September 2017, SPM in patients aged ≤18 years was retrospectively reviewed and clinical features and outcomes between SPM patients with and without PR were analyzed. RESULTS: In total, thirty consecutive occurrences of SPM in 29 patients were finally identified and classified into SPM (n = 24) and SPM plus PR (n = 6) groups. No significant differences in received interventional exams, prophylactic antibiotic administration or restriction of oral intake between the two groups were found. Both groups were treated with hospitalization predominantly; but the SPM plus PR group tended to have longer length of hospital stay (median 5.5 vs. 3 days, p = 0.08). PR was observed more frequently in patients with abnormal serum C-reactive protein (CRP) levels (>5 mg/L), identified predisposing factors, and those with more severe grade of SPM (p = 0.005, 0.001 and < 0.001, respectively). On multivariable regression analysis, the SPM plus PR group exhibited more predisposing factors than did the SPM group (coefficient: 0.514, standard error: 0.136, p < 0.001). All patients were successfully treated without morbidity and mortality. CONCLUSION: Although patients with pneumorrhachis retained a higher CRP level, more identified predisposing factors and prolonged inpatient care, conservative management without an extensive work-up would be an appropriate and favorable strategy in pediatrics with concurrent SPM and PR.

Severe SARS-CoV-2 Pneumonia and Pneumomediastinum/Pneumothorax: A Prospective Observational Study in an Intermediate Respiratory Care Unit.

INTRODUCTION: The occurrence of pneumomediastinum (PM) and/or pneumothorax (PTX) in patients with severe pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was evaluated. METHODS: This was a prospective observational study conducted in patients admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital in Madrid (Spain) between December 14, 2020 and September 28, 2021. All patients had a diagnosis of severe SARS-CoV-2 pneumonia and required noninvasive respiratory support (NIRS): high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). The incidences of PM and/or PTX, overall and by NIRS, and their impact on the probabilities of invasive mechanical ventilation (IMV) and death were studied. RESULTS: A total of 1306 patients were included. 4.3% (56/1306) developed PM/PTX, 3.8% (50/1306) PM, 1.6% (21/1306) PTX, and 1.1% (15/1306) PM + PTX. 16.1% (9/56) of patients with PM/PTX had HFNC alone, while 83.9% (47/56) had HFNC + CPAP/BiPAP. In comparison, 41.7% (521/1250) of patients without PM and PTX had HFNC alone (odds ratio [OR] 0.27; 95% confidence interval [95% CI] 0.13-0.55; p < .001), while 58.3% (729/1250) had HFNC + CPAP/BiPAP (OR 3.73; 95% CI 1.81-7.68; p < .001). The probability of needing IMV among patients with PM/PTX was 67.9% (36/53) (OR 7.46; 95% CI 4.12-13.50; p < .001), while it was 22.1% (262/1185) among patients without PM and PTX. Mortality among patients with PM/PTX was 33.9% (19/56) (OR 4.39; 95% CI 2.45-7.85; p < .001), while it was 10.5% (131/1250) among patients without PM and PTX. CONCLUSIONS: In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia requiring NIRS, incidences of PM/PTX, PM, PTX, and PM + PTX were observed to be 4.3%, 3.8%, 1.6%, and 1.1%, respectively. Most patients with PM/PTX had HFNC + CPAP/BiPAP as the NIRS device, much more frequently than patients without PM and PTX. The probabilities of IMV and death among patients with PM/PTX were 64.3% and 33.9%, respectively, higher than those observed in patients without PM and PTX, which were 21.0% and 10.5%, respectively.

Spontaneous Pneumomediastinum is Not Associated With Esophageal Perforation: Results From a Retrospective, Case-Control Study in a Pediatric Population.

What is the optimal management of spontaneous pneumomediastinum (SPM) and is there a risk of esophageal perforation in patients with SPM? We performed a retrospective case-control study of children through age 21, diagnosed with SPM in one hospital system over 10 years with the primary aim of describing the diagnostic workup, treatment patterns, and clinical outcomes. We hypothesized that SPM is a self-limited disease and is not associated with esophageal injury. Cases were identified using International Classification of Disease codes and excluded for trauma or severe infections. Median age was 16 years, 66% were male (n = 179). Chest radiography was performed in 97%, chest computed tomography (CT) in 33%, and esophagrams in 26%. Follow-up imaging showed resolution in 83% (mean = 17.2 days). SPM was not associated with esophageal perforation. We recommend avoiding CT scans and esophagrams unless there is discrete esophageal concern. Management of SPM should be guided by symptomatology.

Management of Air Leaks in the Newborn.

BACKGROUND: Air leaks, especially pulmonary interstitial emphysema (PIE), are increasingly uncommon respiratory complications of the newborn. Despite PIE having a decreasing incidence, it continues to have a high morbidity and mortality rate. This makes PIE one of the most severe respiratory complications to affect a newborn. Air leaks occur when there is overdistension of the terminal airways or alveoli, which results in air dissecting into extra-alveolar spaces. Recognizing the signs of air leaks is paramount to allow for appropriate diagnosis and treatment of the newborn to improve morbidity and mortality. Treatment modalities range from positioning the newborn in the decubitus position to surgical intervention. PURPOSE: To summarize current evidence on the pathophysiology, risk factors, diagnosis, treatment, and management of PIE and pneumothorax. DATA SOURCES: Two databases were systematically reviewed with key words later. Articles in English with date restrictions from 2016 to current were included. STUDY SELECTION: Inclusion criteria of randomized controlled trials, case studies/reports, and review articles were utilized. Twenty articles, primarily case reports and studies, were reviewed. DATA EXTRACTION: Guidelines for data abstraction were followed via independent extraction by a single observer. RESULTS: Qualitative results were utilized to formulate current treatment of air leaks. IMPLICATIONS FOR PRACTICE: This article provides guidance for frontline neonatal providers on current treatment and management of air leaks in the newborn population.

Pronounced mediastinal emphysema after restorative treatment of the lower left molar-a case report and a systematic review of the literature.

This case report presents an iatrogenic induced mediastinal emphysema after restorative treatment of the lower left second molar, aimed to highlight the potential life-threatening consequences, and providing diagnostics and treatment concepts of complicated dental induced emphysema based on literature review. A 74-year-old female patient was admitted to the emergency department due to a fall on her shoulder. Additional finding was a significant swelling of the face and neck. In the computer tomography of the head, neck, and thorax, a humerus fracture and pronounced soft tissue emphysema from the infraorbital region to the mediastinum was detected. The patient reported that she had been treated by her dentist 4 days earlier. The treatment had to be discontinued after beginning of a pronounced swelling. Other reasons for the emphysema could be excluded out on an interdisciplinary teamwork. The patient was monitored as an inpatient for 5 days and received intravenous antibiotic therapy. This case report shows the rare complication of pronounced mediastinal emphysema after root canal treatment. Emphysema should always be a differential diagnosis of soft tissue swelling and, in case of doubt, a general medical presentation should be made.