Neumomediastino espontáneo en paciente con COVID-19 / Sponteneous pneumomediastinum in patient with COVID-19

Introducción: El neumomediastino espontáneo o síndrome Hamman es una complicación poco frecuente y rara. Se define como la presencia de aire o gas dentro del mediastino sin una causa identificada. Objetivo: Presentar un caso clínico con una complicación poco frecuente, neumomediastino espontáneo, en un paciente con enfermedad por COVID-2019. Caso clínico: Paciente de 86 años con cuadro clínico manifestado por fiebre de 38o C y síntomas respiratorios (tos con secreción blanquecina, disnea de moderados esfuerzos). Se realiza prueba de reacción en cadena de polimerasa para enfermedad por coronavirus 2019, esta fue positiva. Al cuarto día de su hospitalización concurre con empeoramiento clínico dentro que lo destaca tos y disnea progresiva acompañado con saturación de oxigeno menor a 91 por ciento. Se realizaron estudios imagenológicos de alta resolución (angiotomografía computarizada de tórax) en la cual se evidencia la presencia de neumomediastino. Desarrollo: La pandemia por enfermedad por coronavirus 2019 ha dado lugar a una emergencia de salud pública a nivel mundial, en la que es importante que el personal de la salud esté familiarizados con los síntomas, los resultados de imágenes y con las complicaciones de esta enfermedad, como el neumomediastino encontrado en este caso. Conclusión . El neumomediastino espontáneo es una complicación poco frecuente que se presenta en la fase inflamatoria de esta enfermedad(AU)

Introduction: Spontaneous pneumomediastinum or Hamman syndrome is a rare and infrequent complication. It is defined as the presence of air or gas within the mediastinum without an identified cause. Objective: To report a clinical case of spontaneous pneumomediastinum in a patient with COVID-2019, a disease with a rare complication. Clinical case report: We report the case of an 86-year-old patient with a clinical condicion of fever of 38o C and respiratory symptoms (cough with whitish secretions, dyspnea on moderate exertion). He underwent a polymerase chain reaction test for coronavirus disease 2019, which resulted positive. On the fourth day of his hospitalization, he his clinical condition worsened, including cough and progressive dyspnea accompanied by oxygen saturation less than 91 percent. The presence of pneumomediastinum was revealed by high-resolution imaging studies (computed tomography angiography of the chest). Discussion: The 2019 coronavirus disease pandemic has given rise to a global public health emergency, which requires health personnel to be familiar with symptoms, imaging results, and complications of this disease, such as pneumomediastinum found in this case. Conclution: Spontaneous pneumomediastinum is a rare complication that occurs in the inflammatory phase of this disease(AU)

The usefulness of a bilateral trans-cervical pneumomediastinal approach for mediastinoscopic radical esophagectomy: a right transcervical approach is an available option.

OBJECTIVE: We investigated the merits and demerits of right cervical open surgery with right trans-cervical pneumomediastinal approach in mediastinoscopic esophagectomy. METHODS: Ten thoracic esophageal cancer patients were treated using this approach. Under pneumomediastinum via a right neck incision, the right cervical and upper mediastinal paraesophageal lymph nodes were dissected. The left recurrent nerve lymph nodes were dissected using a left trans-cervical pneumomediastinal approach. The subaortic arch to the left tracheobronchial lymph nodes was dissected with a combined right and left trans-cervical crossover approach. RESULTS: The average number of dissected lymph nodes among the right cervical and upper mediastinal paraesophageal lymph nodes identified with a right cervical open/right trans-cervical mediastinoscopic/right thoracoscopic approach was 3.2/4.0/0.6, respectively. The average number of dissected lymph nodes among the subaortic arch to the left tracheobronchial lymph nodes with a right trans-cervical mediastinoscopic/right thoracoscopic approach was 1.5/0.6, respectively. These findings indicate that, without using the right trans-cervical pneumomediastinal approach, it might be impossible to successfully remove some of the right cervical and upper mediastinal paraesophageal lymph nodes and the subaortic arch to the left tracheobronchial lymph nodes lymph nodes. Regarding surgical complications, one case of bilateral recurrent nerve palsy as well as two cases on the right and two cases on the left were noted. CONCLUSIONS: Although the rate of recurrent nerve palsy should still be reduced, a bilateral (especially right-sided) trans-cervical pneumomediastinal approach is an available option for achieving sufficient upper mediastinal lymph node dissection and esophagectomy.

Mediastinal Parathyroidectomy Using a Cervical Approach Under a Pneumomediastinum.

Video-assisted thoracoscopic surgery (VATS) and robotic surgery are minimally invasive surgeries for mediastinal parathyroid adenomas. However, a transthoracic approach is often difficult in the cervicothoracic transition area because of the limited visual field. We report a novel minimally invasive surgery for an ectopic parathyroid adenoma in the middle mediastinum using a cervical approach under a pneumomediastinum.

Pneumomediastino, pneumotórax e enfisema subcutâneo em cão com pneumopatia e infecção pelo vírus da cinomose: relato de caso / Pneumomediastinum, pneumothorax and subcutaneous emphysema in a dog with pneumopathy and infection by the canine distemper virus: case report

Relata-se um caso de pneumomediastino, pneumotórax e enfisema subcutâneo em um cão com pneumopatia associada à cinomose. As queixas principais eram tosse, secreção nasal purulenta, apatia e enfisema subcutâneo em face, região cervical e torácica. O exame radiográfico evidenciou pneumomediastino, pneumotórax e broncopneumopatia grave com áreas de consolidação pulmonar. Teste rápido imunocromatográfico para detecção de antígeno da cinomose foi positivo e houve melhora dos sinais respiratórios com antibioticoterapia, porém o quadro evoluiu para alterações neurológicas. De acordo com a revisão de literatura realizada, não há casos semelhantes relatados.(AU)

A case of pneumomediastinum, pneumothorax and subcutaneous emphysema in a dog with pneumopathy associated to distemper is reported. The main complaints were cough, purulent nasal discharge, lethargy and subcutaneous emphysema in the face, neck, and chest area. Radiographic examination showed pneumomediastinum, pneumothorax, and severe bronchopneumopathy with areas of pulmonary consolidation. Rapid test for canine distemper antigen detection was positive. After the antibiotic therapy there was an improvement of respiratory signs; however, the patient developed neurological symptomatology. As far as the author´s knowledge by literature review carried out, there are no similar cases reported.(AU)

Siphoning diesel: a fatal mistake.

Diesel is commonly used as fuel for engines and is distilled from petroleum. Diesel has toxic potential and can affect multiple organs. Exposure can occur after ingestion, inhalation or through the dermal route. The practice of siphoning diesel using a rubber tubing and the mouth is common in rural communities. This can lead to accidental ingestion and aspiration. Here we report a case of a patient who accidentally ingested diesel during siphoning, which caused extensive erosion of the oral cavity and oesophagus leading to pneumomediastinum and severe chemical lung injury. The patient responded well initially to steroids and supportive care but required prolonged hospitalisation. He developed complications of nosocomial infection and succumbed 23 days after admission.

Pneumomediastinum and pneumothorax during emergency tracheotomy under spontaneous ventilation: Macklin meets Müeller? / Neumomediastino y neumotórax en la traqueotomía urgente en ventilación espontánea. Cuando Macklin encontró a Müeller

Potentially serious complications associated to emergency tracheotomy continue being a matter of concern. We review the pathogenesis of gas leakage in this setting and discuss about the possible mechanisms involved in its cause. We present two cases of pneumomediastinum, subcutaneous emphysema and pneumothorax in the context of emergency tracheotomy under spontaneous ventilation, finally resolved by chest drainage. The combination of overly negative pleural pressures due to extreme inspiratory efforts in the context of an almost completely obstructed airway together with over-pressurized alveoli because of gaseous entrapment secondary to serious expiratory obstruction appears to be the most plausible primary cause of air leaks in our patients. Understanding the underlying mechanisms evolved in its production will help clinicians to suspect and diagnose this phenomenon (AU)

Las complicaciones graves asociadas a la traqueotomía urgente continúan siendo un desafío clínico. En este trabajo revisamos y discutimos la fisiopatología de la fuga aérea en el contexto de la traqueotomía urgente. Presentamos dos casos de neumomediastino, enfisema subcutáneo y neumotórax en el curso de sendas traqueotomías urgentes realizadas sobre pacientes en ventilación espontánea que se resolvieron tras inserción de drenaje pleural. Nuestra conclusión es que la combinación de presiones pleurales inspiratorias muy negativas por el esfuerzo inspiratorio contra una vía aérea obstruida junto con la presencia de alveolos hiper-presurizados por el atrapamiento gaseoso espiratorio constituyen la base etiopatogénica del proceso. La comprensión de los mecanismos que subyacen en la generación del neumotórax y neumomediastino en este contexto facilitará que los clínicos sospechen y diagnostiquen el cuadro (AU)

¿Es el neumomediastino y enfisema cervical un signo de mal pronóstico en la dehiscencia de anastomosis colorrectal? / Is pneumomediastinum and cervical emphysema a sign of poor prognosis in colorectal anastomosis leakage?

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Clinical presentation of air leak in an infant with undiagnosed cystic fibrosis: a case report.

INTRODUCTION: Air leak is a well-recognized complication of advanced cystic fibrosis in older children and adults but is extremely rare in infants. To the best of our knowledge, this is the youngest reported pediatric case of an air leak from a major airway. CASE PRESENTATION: A 4-month-old Yamani baby girl with a family history of cystic fibrosis initially presented with a history of a persistent paroxysmal cough for 3 weeks and vomiting for 1 week. Laboratory evaluation indicated pseudo-Bartter's syndrome. Imaging showed a tracheal tear with pneumomediastinum and subcutaneous emphysema that was treated conservatively. CONCLUSIONS: This case highlights the possibility of air leak in the population of young patients with cystic fibrosis and it shows a successful conservative management of tracheal tear. Physicians should consider cystic fibrosis in infants presenting with air leak.

[Thoracoscopic thymectomy with carbon dioxide insufflation in the mediastinum]. / Timectomía toracoscópica con insuflación de dióxido de carbono.

The case is presented of a 71 year-old male, diagnosed with a thymoma. A thoracoscopic thymectomy was performed using the carbon dioxide insufflation technique in the mediastinum. During the procedure, while performing one-lung ventilation, the patient's respiration worsened. The contralateral lung had collapsed, as carbon dioxide was travelling from the mediastinum to the thorax through the opened pleura. Two-lung ventilation was decided upon, which clearly improved oxygenation in the arterial gases and airway pressures. Both pH and pCO2 stabilized. The surgical approach and the carbon dioxide technique were continued because 2-lung ventilation did not affect the surgical procedure. This technique has many serious complications and it should always be performed using 2-lung ventilation.

Update on anesthetic complications of robotic thoracic surgery.

In the last decade, there has been increasing use of the da Vinci® robot surgical system to perform minimally invasive thoracic surgery. The robotic technology can be applied for surgery of the lungs, mediastinum, and esophagus. A number of case reports have been shown steep learning curve, and promising surgical outcome with this new technology. However, anesthesia management of the robotic thoracic surgery can be complex and requires further education. For example, most of the cases require sufficient lung collapse in order to provide adequate surgical field. In addition, a unique operative setting, such as patient positioning and capnothorax can make anesthesia management further challenging. Hence, anesthesiologists should have better awareness of adverse events or complications related to the robotic surgery to accomplish successful anesthesia management. This review will focus on the potential complications of robotic thoracic surgery involving the lungs, mediastinum and esophagus.

Neumomediastino espontáneo / Spontaneous Pneumomediastinum

El neumomediastino espontáneo (NME) es una patología infrecuente que consiste en la presencia de aire libre en los tejidos blandos del mediastino sin evidencia de lesión de la vía aérea o digestiva subyacente, y sin antecedente de procedimiento médico previo que lo explique. Esta entidad afecta con mayor frecuencia a hombres jóvenes, es de comportamiento benigno y generalmente es autolimitada. En el artículo se presenta el caso de un joven de 21 años de edad que presenta un neumomediastino espontáneo. Se hace luego una breve revisión de la literatura acerca de la epidemiología, la fisiopatología, las características clínicas y los hallazgos imaginológicos de esta entidad.

Spontaneous pneumomediastinum (SPM) is an uncommon condition characterized by the presence of free air in the soft tissues of the mediastinum without evidence of underlying injury in the airway or esophagus, or a history of prior medical procedure. This condition most often affects young men, it is usually benign and self-limited. In this paper we present the case of a 21-year-old man who presents a spontaneous pneumomediastinum, then we are going to perform a brief review of the literature regarding the epidemiology, pathophysiology, clinical features and imaging findings in this entity.

Neumotórax bilateral y neumomediastino tras microcirugía transoral con láser y traqueotomía / Bilateral and pneumomediastinal pneumothorax after transoral laser microsurgery and tracheotomy

La microcirugía transoral con láser CO2 se ha convertido en una alternativa cada vez más empleada para el tratamiento del cáncer de laringe y faringe. Entre las ventajas que aporta frente a la cirugía abierta y la radioterapia, se encuentran su menor invasividad, mayor precisión, mejor preservación funcional del órgano y menor morbilidad asociada al procedimiento. No obstante, esta técnica quirúrgica no está exenta de complicaciones, algunas hasta ahora poco frecuentes, pero de gran trascendencia clínica. Presentamos el caso de una paciente que en el contexto de una microcirugía con traqueotomía por cáncer de laringe sufrió un enfisema subcutáneo, neumomediastino y neumotórax bilateral precisando de las medidas pertinentes para su control y estabilización, que se describen. Además, se realiza una revisión actual en la literatura, sobre las consideraciones anestésicas y las principales complicaciones perioperatorias de la microcirugía con láser(AU)

Transoral laser CO2 microsurgery is becoming an increasing used treatment option for cancer of the larynx and the pharynx. Amongst the advantages it has compared to open surgery and radiotherapy are, it less invasiveness, greater precision, better functional preservation of the organ, and less procedure-associated morbidity. However, this surgical technique is not without its complication, some being rare up until now, but with great clinical importance. We present the case of a patient subjected to microsurgery with a tracheotomy due to cancer of the larynx, who suffered a subcutaneous emphysema, and a bilateral and pneumomediastinal pneumothorax, requiring the appropriate measures for its control and stabilisation, which are described. A review was also performed of the current literature as regards anaesthetic considerations and the main peri-operative complications of laser microsurgery(AU)

Técnica modificada de obtención de muestras del mediastino mediante punción transbronquial bajo guía de ecografía endobronquial: resultados de un estudio prospectivo observacional / Modified Technique for Obtaining Mediastinal Samples With Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Results from a Prospective Observational Study

Antecedentes: La aspiración mediante punción transbronquial bajo guía de ecografía transbronquial (EBUS-TBNA) es un método ampliamente aceptado para la obtención de muestras de ganglios linfáticos mediastínicos tanto benignos como malignos. Se presentan los resultados obtenidos con una modificación que simplifica la técnica de obtención de muestras denominada «capilaridad con aguja fina» o EBUS-FNC. Métodos: Estudio prospectivo observacional de 44 pacientes consecutivos a los que se practicó una EBUS en la Clínica de la Universidad de Navarra de Pamplona (España). Todas las muestras se obtuvieron mediante EBUS-FNC en vez de con la EBUS-TBNA convencional. No se aplicó aspiración y en ningún momento se retiró por completo el estilete interno. Resultados: La exploración del mediastino mediante EBUS identificó la presencia de adenopatías o masas mediastínicas en 38 pacientes (86,4%). Se obtuvieron muestras de más de un ganglio linfático en 23 pacientes (52,3%). La EBUS-FNC proporcionó un material adecuado y representativo para realizar la interpretación en todos los pacientes, y el rendimiento diagnóstico fue del 87%. La sensibilidad para la detección del cáncer de pulmón con la EBUS-FNC fue del 84%. Se registraron complicaciones menores tan solo en 2 pacientes (4,5%). Conclusiones: Nuestro estudio sugiere que la EBUS-FNC es una técnica segura y comparable a la EBUS-TBNA en cuanto a su eficacia y obtención de muestras adecuadas(AU)

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a widely-accepted method for obtaining both benign and malignant mediastinal lymph node samples. We present the results obtained with a modification that simplifies sampling, known as fine-needle capillary sampling or EBUS-FNC. Methods: A prospective observational study with 44 consecutive patients who underwent EBUS at the University of Navarra Clinic in Pamplona, Spain. All samples were obtained by EBUS-FNC instead of by conventional EBUS-TBNA. No suction was used, and the internal stylus was not completely withdrawn at any time. Results: The examination of the mediastinum by means of EBUS identified the presence of lymphadenopathies or mediastinal masses in 38 patients (86.4%). Samples were taken from more than one lymph node in 23 patients (52.3%). EBUS-FNC provided adequate and representative material for interpretation in all patients, and diagnostic performance was 87%. Sensitivity for the detection of lung cancer with EBUS-FNC was 84%. Mild complications were only recorded in two patients (4.5%). Conclusions: Our study suggests that EBUS-FNC is a safe technique, comparable to EBUS-TBNA in efficacy, and is able to obtain adequate samples(AU)

Bilateral bullectomy through uniportal video-assisted thoracoscopic surgery combined with contralateral access to the anterior mediastinum.

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) has been a surgical intervention of choice for the treatment of spontaneous pneumothorax (SP) with lung bulla. Our objective was to introduce a uniportal VATS approach for simultaneous bilateral bullectomy and to evaluate its therapeutic efficacy. METHODS: Between May of 2011 and January of 2012, five patients underwent bilateral bullectomy conducted using this approach. All of the patients presented with bilateral SP. Preoperative HRCT revealed that all of the patients had bilateral apical bullae. We reviewed the surgical indications, surgical procedures, and outcomes. RESULTS: All of the patients were successfully submitted to this approach for bilateral bullectomy, and there were no intraoperative complications. The median time to chest tube removal was 4.2 days, and the median length of the postoperative hospital stay was 5.2 days. The median postoperative follow-up period was 11.2 months. One patient experienced recurrence of left SP three weeks after the surgery and underwent pleural abrasion. CONCLUSIONS: Bilateral bullectomy through uniportal VATS combined with contralateral access to the anterior mediastinum is technically reliable and provides favorable surgical outcomes for patients with bilateral SP who develop bilateral apical bullae. However, among other requirements, this surgical procedure demands that surgeons be experienced in VATS and that the appropriate thoracoscopic instruments are available.

Bulectomia bilateral por cirurgia torácica vídeo-assistida uniportal combinada com acesso contralateral ao mediastino anterior / Bilateral bullectomy through uniportal video-assisted thoracoscopic surgery combined with contralateral access to the anterior mediastinum

OBJETIVO: A cirurgia torácica vídeo-assistida (CTVA) tem sido uma intervenção de escolha para o tratamento de pneumotórax espontâneo (PS) com bolha pulmonar. Nosso objetivo foi apresentar uma abordagem de CTVA uniportal unilateral para bulectomia bilateral e avaliar sua eficácia terapêutica. MÉTODOS: Entre maio de 2011 e janeiro de 2012, cinco pacientes foram submetidos a bulectomia bilateral por essa abordagem. Todos apresentavam PS bilateral. A TCAR pré-operatória mostrou que todos os pacientes tinham bolhas bilaterais no pulmão apical. As indicações cirúrgicas, os procedimentos de operação e os desfechos foram revisados. RESULTADOS: Todos os pacientes foram submetidos com sucesso a essa abordagem para bulectomia bilateral, sem complicações intraoperatórias. A mediana de tempo para a retirada do dreno torácico foi de 4,2 dias, e a mediana do tempo de hospitalização no pós-operatório foi de 5,2 dias. A mediana de seguimento pós-operatório foi de 11,2 meses. Um paciente teve recidiva de PE do lado esquerdo três semanas após a cirurgia e foi submetido a abrasão pleural. CONCLUSÕES: A bulectomia bilateral utilizando CTVA uniportal combinada com acesso contralateral ao mediastino anterior é tecnicamente confiável e promove desfechos favoráveis para pacientes com PS que desenvolvem bolhas bilaterais no pulmão apical. Entretanto, para a realização desse procedimento cirúrgico, são necessários cirurgiões com experiência em CTVA, instrumentos toracoscópicos longos, entre outras exigências.

OBJECTIVE: Video-assisted thoracoscopic surgery (VATS) has been a surgical intervention of choice for the treatment of spontaneous pneumothorax (SP) with lung bulla. Our objective was to introduce a uniportal VATS approach for simultaneous bilateral bullectomy and to evaluate its therapeutic efficacy. METHODS: Between May of 2011 and January of 2012, five patients underwent bilateral bullectomy conducted using this approach. All of the patients presented with bilateral SP. Preoperative HRCT revealed that all of the patients had bilateral apical bullae. We reviewed the surgical indications, surgical procedures, and outcomes. RESULTS: All of the patients were successfully submitted to this approach for bilateral bullectomy, and there were no intraoperative complications. The median time to chest tube removal was 4.2 days, and the median length of the postoperative hospital stay was 5.2 days. The median postoperative follow-up period was 11.2 months. One patient experienced recurrence of left SP three weeks after the surgery and underwent pleural abrasion. CONCLUSIONS: Bilateral bullectomy through uniportal VATS combined with contralateral access to the anterior mediastinum is technically reliable and provides favorable surgical outcomes for patients with bilateral SP who develop bilateral apical bullae. However, among other requirements, this surgical procedure demands that surgeons be experienced in VATS and that the appropriate thoracoscopic instruments are available.

Neumomediastino espontáneo primario / No disponible

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