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Pneumomediastinum Treatment & Management

  • Author: Patrick L Carolan, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
Updated: Apr 19, 2016

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.


Surgical Care

Surgical intervention has rarely been described in pneumomediastinum. Its use is reserved for pneumomediastinum leading to marked cardiorespiratory compromise or circumstances of defined esophageal or tracheal tear. However, Cunningham et al (2013) present case outcomes in 2 pediatric patients with tracheal injury managed conservatively, suggesting that this may be a treatment option in some cases.[41]

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.[42] CT-guided placement may also be considered.



No special diet is indicated.



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

Contributor Information and Disclosures

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, International Society for the Study and Prevention of Perinatal and Infant Death

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Chief Editor

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Children's Hospital, Rush University Medical Center

Girish D Sharma, MD, FCCP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Additional Contributors

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, American Thoracic Society

Disclosure: Received honoraria from Genentech for speaking and teaching; Received honoraria from Genentech for consulting; Partner received consulting fee from Boston Scientific for consulting; Received honoraria from Gilead for speaking and teaching; Received consulting fee from Caremark for consulting; Received honoraria from Vertex Pharmaceuticals for speaking and teaching.


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.

David J Vaughan, MBBCH, MRCPI Consultant Pediatrician, Department of Pediatrics, Our Lady of Lourdes Hospital, Ireland

David J Vaughan is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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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. 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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