Pneumomediastinum in COVID-19 disease: Outcomes and relation to the Macklin effect.

AIM: Pneumomediastinum (PM) is associated with several etiologies and mechanisms. Although it has been described more than 100 years ago, the literature is limited to small retrospective studies. This study aimed to follow patients with coronavirus disease (COVID-19) that developed PM during hospitalization and describe their clinical and radiological evolution. METHODS: A prospective cohort was developed with patients with PM, excluding those with aerodigestive trauma, inside a hospital COVID-19 dedicated hospital. Clinical variables including onset of symptoms, hemodynamic instability, associated complications, the need of interventions, and disease course were all recorded. Also, radiological findings such as the presence of the Macklin effect, extension of lung involvement by COVID-19, and characteristics of the PM were analyzed. RESULTS: Twenty-one patients with non-traumatic PM were followed, resulting in an overall incidence of 0.5% during the study period. Seven (33%) patients had associated pneumothorax and malignant/tension PM was observed in three (14%) cases. The Macklin effect could be found in 11 patients (52%) and the majority of them had more than 50% of lung involvement due to COVID-19. The mortality rate was 49%; however, no deaths were directly related to the PM. CONCLUSIONS: PM incidence is probably increased in the severe acute respiratory syndrome caused by COVID-19, especially in those with greater involvement of the lungs, and the Macklin effect may be an important underlying mechanism of this complication. Usually, PM has a benign course, but complications like tension/malignant PM may occur requiring prompt detection and intervention.

Delayed Tension Symptomatic Pneumoperitoneum After POEM Requiring Needle Decompression.

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is an effective modality for the management of achalasia. Tension pneumoperitoneum is a significant complication that causes hemodynamic instability, generally within the periprocedural period. METHODS: Here, we report 2 cases of delayed tension pneumoperitoneum that was recognized and treated several hours after uncomplicated POEM. RESULTS: These cases illustrate the importance of continued vigilance for this complication outside of the immediate periprocedural period as well as the utility of computed tomography-guided aspiration in managing it. DISCUSSION: When discharging patients after POEM, caregivers should be aware of this rare complication and alert patients to return for immediate care when it happens.

Images of the month: An incidental finding of spontaneous pneumomediastinum (Hamman's syndrome) secondary to diabetic ketoacidosis during the coronavirus pandemic.

Hamman's syndrome is a spontaneous pneumomediastinum and is described as a rare complication of diabetic ketoacidosis (DKA). It typically follows a self-limiting course after successful treatment of the underlying DKA. We describe a case of a 28-year-old woman with type 1 diabetes presenting with facial pain, vomiting and abdominal pain. She also complained of dyspnoea and chest pain. She was diagnosed and treated for DKA triggered by a dental abscess. Given the presentation during the coronavirus pandemic, a computed tomography pulmonary angiography was performed in line with the diagnostic pathway for COVID-19, which incidentally showed a significant pneumomediastinum and pneumopericardium. The patient was initially investigated for oesophageal rupture secondary to vomiting (Boerhaave's syndrome), however, remained clinically stable throughout. Follow-up computed tomography showed near-complete resolution of pneumomediastinum with no intervention other than treatment of DKA. This therefore confirmed Hamman's syndrome.We propose that given the benign nature of the condition and the incidental finding in this report, as well as poor identification of mediastinal gas on chest X-ray, Hamman's syndrome is more common than reported.

A case of a critically injured diver with multiorgan failure and severe pulmonary overinflation syndrome in a resource-limited setting.

A diver practicing controlled emergency ascent training on the island of Guam suffered bilateral pneumothorax, pneumomediastinum, coronary arterial gas embolism, and developed multiple organ dysfunction syndrome. Due to limitations of available resources he was medically managed in the intensive care unit until he could be transferred to University of California San Diego for definitive management. We provide an account of our management of the patient, the pathophysiology of injury as well as a review of the safety of recreational diving skills training, current standards of practice and potential pitfalls when considering proper management of a critically injured diver.

A 64-Year-Old Man With Rapidly Progressive Respiratory Failure and Pneumomediastinum.

CASE PRESENTATION: A 64-year-old man presented for consideration for lung transplant. He had a history of previous tobacco use, OSA on CPAP therapy, and gastroesophageal reflux disease. He worked as a design engineer. The patient had a 4-year history of dyspnea on exertion, followed with periodic CT scan of the chest. Nine months prior to his evaluation for lung transplant, the patient developed worsening of dyspnea, dry cough, poor appetite, and weight loss. At times, the cough was violent and associated with chest pressure. He was prescribed systemic corticosteroids and antibiotics without improvement. Four months later, the patient noted sudden onset of severe chest pain and worsening dyspnea. A CT scan of the chest demonstrated extensive pneumomediastinum in addition to changes consistent with pulmonary fibrosis. An esophagogram showed thickening of the distal esophagus, but no signs of perforation. He was prescribed supplemental oxygen and advised to stop the use of CPAP. The patient sought a second opinion. A CT scan of the chest showed improvement of the pneumomediastinum and extensive fibrotic lung disease. Pulmonary function tests (PFTs) were consistent with a restrictive pattern, decreased diffusing capacity (Dlco), and a preserved residual volume over total lung capacity ratio. The patient was prescribed systemic corticosteroids with no improvement of his symptoms. Repeat PFTs showed further decline of Dlco, and he was referred for lung transplant evaluation.

Neumomediastino y enfisema subcutáneo espontáneo: síndrome de Hamman / Spontaneous Pneumomediastinum and Subcutaneous Emphysema: Hamman's Syndrome

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Smartphone aiding in analysis of Hamman's sign.

Hamman's sign refers to an unusual click that occurs in synchrony with heart sounds, and is pathognomonic for left-sided pneumothorax and spontaneous mediastinum. In this case, a 17-year-old man living in a rural area used his smartphone to record an audible clicking sound emanating from his thorax. This occurred following coughing episodes secondary to an upper respiratory tract infection. Initially, this prompted a request for an echocardiogram to exclude structural cardiac anomalies; however, Hamman's sign was also considered. This facilitated the timely diagnosis of pneumothorax to be made via a simple chest radiograph, one of the only imaging modalities available at the patient's rural health service. To promote awareness of this rare clinical phenomenon, this report also presents the patient's own sound recording of Hamman's sign and corresponding chest radiographs.

A comparative study of pneumomediastinums based on clinical experience.

BACKGROUND: Pneumomediastinum (PM) is the term which defines the presence of air in the mediastinum. PM has also been described as mediastinal emphysema. PM is divided into two subgroups called as Spontaneous PM (SPM) and Secondary PM (ScPM). METHODS: A retrospective comparative study of the PM diagnosed between February 2010 and July 2018 is presented. Forty patients were compared. Clinical data on patient history, physical characteristics, symptoms, findings of examinations, length of the hospital stay, treatments, clinical time course, recurrence and complications were investigated carefully. Patients with SPM, Traumatic PM (TPM) and Iatrogenic PM (IPM) were compared. RESULTS: SPM was identified in 14 patients (35%). In ScPM group, TPM was identified in 16 patients (40%), and IPM was identified in 10 patients (25%). On the SPM group, the most frequently reported symptoms were chest pain, dyspnea, subcutaneous emphysema and cough. CT was performed to all patients to confirm the diagnosis and to assess the possible findings. All patients prescribed prophylactic antibiotics to prevent mediastinitis. CONCLUSION: The present study aimed to evaluate the clinical differences and managements of PMs in trauma and non-trauma patients. The clinical spectrum of pneumomediastinum may vary from benign mediastinal emphysema to a fatal mediastinitis due to perforation of mediastinal structures. In most series, only the SPM was evaluated in many aspects, but there are fewer studies comparing the evaluation and management of traumatic and non-traumatic PMs. The patients with TPM who have limited trauma to the thorax and who do not have mediastinal organ injury in their imaging studies can be followed up and treated like SPM patients who do not have mediastinal organ injury, and both have good clinical course.

Pneumomediastinum as a complication of cocaine abuse.

A 26-year-old male presented with a 24-hour history of pleuritic chest pain following intranasal cocaine insufflation. He was a smoker, cannabis and alcohol user. Cardiovascular and respiratory examinations were unremarkable.His admission blood tests were within normal limits. The admission electrocardiogram (ECG) showed sinus rhythm, with ST-segment elevation in an inferolateral distribution. This appeared to be an early repolarisation abnormality, with no evolving changes.His chest radiogram showed a double outline at the left heart border with subcutaneous gas collection over the left supraclavicular fossa but no evidence of pneumothorax. A computed tomography (CT) showed prominent mediastinum with gas tracking into the neck but no connection to the oesophagus or pneumothorax.He was managed conservatively and a repeat chest radiogram after 48 hours showed improvement.

Neumorraquis: un hallazgo en el neumomediastino espontaneo / Pneumorrhachis: A finding in spontaneous pneumomediastinum

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Enfisema subcutáneo neonatal / Neonatal subcutaneous emphysema

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Pneumomediastinum, ST elevation and urgent cardiac catheterisation: a crucial triad?

Pneumomediastinum (PNMD) entails the presence of air or other gas in the mediastinum and is also known as mediastinal emphysema. PNMD may cause a wide variety of signs and symptoms, as well as ECG abnormality, including ST segment changes. We present a 56-year-old man admitted to our hospital after a facial trauma. After undergoing tracheostomy, he complained of chest discomfort. A chest X-ray in the posteroanterior view showed PNMD, and an ECG was suggestive of inferior-lateral wall myocardial infarction. An urgent cardiac catheterisation identified a critical obstruction at the origin of the right coronary artery. Following a balloon angioplasty, chest discomfort continued; and the ECG ST segments did not show any dynamic change during the subsequent 72 hours. We urge clinicians to perform a comprehensive workup for every patient presenting with PNMD and ST segment changes, to prevent unnecessary invasive procedures.

Spontaneous pneumomediastinum in limited cutaneous systemic sclerosis and myositis overlap.

A 58-year-old man with limited cutaneous systemic sclerosis and myositis overlap complicated by interstitial lung disease presented with several months of progressive dyspnoea and weakness. CT chest revealed extensive pneumomediastinum that was not present on imaging 6 months before this study and appeared to be spontaneous, with no preceding trauma, infection or invasive procedures.