Pneumomediastinum Follow-up

  • Author: Patrick L Carolan, MD; Chief Editor: Michael R Bye, MD   more...
 
Updated: Mar 28, 2012
 

Further Inpatient Care

Patients should be closely monitored (clinically and with pulse oximetry or cardiorespiratory monitors) to anticipate development of more serious complications associated with pneumomediastinum (PM), such as tension pneumomediastinum, pneumothorax, or pneumopericardium. The patient should avoid strenuous physical activity; forced expiratory maneuvers such as spirometry or pulmonary function testing should also be avoided. If esophageal perforation has occurred, the risk of developing mediastinitis is very high. These patients should be observed very closely for evolving fever and signs of worsening respiratory distress or systemic sepsis.

Esophageal perforation, with the attendant risk of developing mediastinitis, may require treatment with broad-spectrum antibiotics.

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Further Outpatient Care

The patient should avoid risk factors associated with the development of pneumomediastinum. However, published evidence to support the following guidelines is sparse, and the following recommendations are in large part drawn from those relating to pneumothorax.

Physical activities associated with the development of pneumomediastinum (eg, weight lifting, scuba diving, playing wind instruments) should be minimized. Indeed, extrapolating from the data relating to air leaks and scuba diving, a history of pneumomediastinum should be considered an absolute contraindication to diving. The authors suggest abstaining from other activities listed above for a minimum period of 6 months. If pneumomediastinum recurs, avoidance of these activities permanently would be advisable.

Medical conditions associated with the development of pneumomediastinum should be treated aggressively. These include asthma and recurrent vomiting (eg, from gastroesophageal reflux disease [GERD], chemotherapy, cyclic vomiting, bulimia).[31]

Pneumomediastinum has been reported in association with childbirth (vaginal delivery).

Children at risk for pneumomediastinum or with a history of developing pneumomediastinum should be fully vaccinated, including vaccinations for pertussis and influenza.

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Inpatient & Outpatient Medications

No specific medical therapy is indicated for the prevention or treatment of pneumomediastinum. As noted above, associated conditions should be treated aggressively.

Those with a history of pneumomediastinum may benefit from antitussives during coughing spells.

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Transfer

Intensive care

Patients with severe respiratory distress, increasing oxygen requirements, other air leak syndromes, or signs of cardiovascular compromise may require transfer to a pediatric intensive care unit for further monitoring and management.

Pediatric tertiary care

If the patient has cardiorespiratory compromise or a serious condition associated with a pneumomediastinum (eg, esophageal perforation), transfer to a pediatric tertiary care facility may be necessary.

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Deterrence/Prevention

Avoidance of high-risk behavior

High-risk behavior includes strenuous athletic activities, scuba diving, weight lifting, and playing wood instruments.

Paroxysmal coughing, screaming, and crying may all result in pneumomediastinum.

Inhalation of both legal drugs (cigarettes) and illicit drugs (eg, cocaine, marijuana) should be avoided.

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Complications

Associated air leaks

Other air leak syndromes (in particular, pneumothorax) may be observed in conjunction with pneumomediastinum.

Subcutaneous emphysema is commonly noted, although it is not usually associated with serious complications.

Tension pneumomediastinum

Although rare, tension pneumomediastinum may occur, leading to compression of the great veins, compromising venous return, which may result in hypotension and hypoxemia secondary to ventilation/perfusion mismatch.

Mediastinitis

Pneumomediastinum following massive vomiting may be associated with Boerhaave syndrome; developing mediastinitis is a risk.

Associated conditions

Complications may arise from associated conditions such as asthma, a foreign body, or drug ingestion.

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Prognosis

Although recurrent pneumomediastinum is a risk, the pneumomediastinum is almost invariably benign, with morbidity or mortality principally attributable to the associated or precipitating condition.

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Patient Education

Advise the patient to avoid high-risk activities. Instructions include the following:

  • Avoid strenuous athletic activities, particularly those involving Valsalva maneuvers such as weight lifting.
  • Avoid playing woodwind instruments.
  • Avoid barotrauma from activities such as flying, parachuting, or scuba diving.
  • Maintain good asthma control. Ensure that influenza and pertussis vaccinations are current.
  • Avoid smoking and inhalation of illicit drugs.

For patient education resources, see the Lung and Airway Center, as well as Emphysema and Chest Pain.

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Contributor Information and Disclosures
Author

Patrick L Carolan, MD  Adjunct Associate Professor, Departments of Pediatrics, Family Practice, and Community Health, University of Minnesota Medical School; Medical Director of Minnesota Sudden Infant Death Center; Attending Staff, Department of Emergency Services, Children's Hospitals and Clinics of Minnesota

Patrick L Carolan, MD is a member of the following medical societies: American Academy of Pediatrics and International Society of SIDS Researchers

Disclosure: Nothing to disclose.

Specialty Editor Board

Susanna A McColley, MD  Professor of Pediatrics, Northwestern University, The Feinberg School of Medicine; Director of Cystic Fibrosis Center, Head, Division of Pulmonary Medicine, Children's Memorial Medical Center of Chicago

Susanna A McColley, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Sleep Disorders Association, and American Thoracic Society

Disclosure: Genentech Honoraria Speaking and teaching; Genentech Honoraria Consulting; Boston Scientific Consulting fee Consulting; Gilead Honoraria Speaking and teaching; Caremark Consulting fee Consulting; Vertex Pharmaceuticals Honoraria Speaking and teaching

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Heidi Connolly, MD  Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center; Professor of Clinical Pediatrics, State University of New York at Stony Brook

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD  Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author David J Vaughan, MBBCh, to the original writing and development of this article.

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This chest radiograph (posteroanterior and lateral view) is from a 3-year-old girl with a history of prematurity, chronic lung disease, and asthma who presented with a viral pneumonitis and persistent cough. A chest radiograph on admission did not reveal any air leak. On the posteroanterior view, a pneumomediastinum (arrow) is noted. Also, extensive subcutaneous air is observed.
The chest radiograph is taken from an adolescent girl with status asthmaticus who was intubated for respiratory failure. A rim of air consistent with a pneumomediastinum may be observed along the upper left border of the heart. Subcutaneous air is observed in the soft tissues of the neck. She required very high peak inspiratory pressures (50 cm H2), which in conjunction with marked air trapping due to her asthma, caused alveolar rupture, allowing air to track to the mediastinum. A central venous line was placed.
On the lateral radiograph from the patient in Media file 2, anterior mediastinal air is observed. Left lower lobe atelectasis is also present. The child was asymptomatic and was discharged 2 days later.
Chest radiographs in anteroposterior (AP) and lateral projections obtained in a 9-year-old girl with wheezing and pneumonitis. The arrows highlight the "spinnaker sail sign" in which free mediastinal air lifts the thymus off of the heart and major vessels.
Subcutaneous Emphysema and Pneumothorax
 
 
 
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