Pneumomediastinum Treatment & Management

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

Medical Care

Medical therapy depends on the clinical status of the patient. In general, most children with pneumomediastinum (PM) are asymptomatic, and the natural course is for the pneumomediastinum to spontaneously resolve.

Mechanical ventilation

Although mechanical ventilation (MV) may cause air leaks, including pneumomediastinum, continuing the MV and even escalating respiratory support may be necessary depending on the severity of the underlying respiratory distress and the degree of compromise caused by the air leak. Principle objectives include the use of the lowest pressures or tidal volumes necessary to achieve satisfactory carbon dioxide removal and oxygenation. Permissive hypercapnia, a ventilatory strategy that is based on maintaining adequate oxygenation and blood pH while allowing high partial pressure of carbon dioxide, allows for ventilatory support while minimizing barotrauma.

Case reports have described the successful use of high-frequency oscillatory ventilation (HFOV) in a child with acute respiratory distress syndrome (ARDS) and pneumomediastinum.

Asynchronous independent lung ventilation has been reported as a therapy for pneumomediastinum.

Nitrogen washout with inhalation of 100% oxygen has been suggested as a possible therapy for pneumomediastinum. The actual indications for this procedure are unclear.

Adequate analgesia is necessary in children with pain.

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Surgical Care

Surgical intervention has rarely been described in pneumomediastinum. Its use is reserved for pneumomediastinum leading to marked cardiorespiratory compromise.

The use of mediastinoscopy in alleviating life-threatening pneumomediastinum has been reported in a small number of cases.

Percutaneous placement of mediastinal drainage tubes has been reported. Chau et al describe percutaneous decompression of tension pneumomediastinum under fluoroscopic guidance using a drainage catheter and Heimlich valve in a 2-year-old girl with dermatomyositis and lung involvement.[30] CT-guided placement may also be considered.

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Diet

No special diet is indicated.

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Activity

Patients should avoid strenuous physical activity until resolution of the pneumomediastinum has occurred.

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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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