Pneumomediastinum Workup

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

Laboratory Studies

The following studies are indicated in suspected cases of pneumomediastinum (PM):

ABG

ABG should be checked in individuals presenting with respiratory distress.

Depending on the severity of the underlying respiratory compromise, the blood gas may be normal or may reveal hypoxia, hypocarbia, or hypercarbia.

Cardiac enzymes

Evidence of myocardial infarction should be sought in individuals with chest pain of unclear etiology. Myocardial infarction is very rare in children. However, it has been seen in patients with the coronary vasculitis of Kawasaki syndrome and with congenital coronary artery anomalies.

Toxicology

Blood or urine should be tested for the presence of illicit drugs when indicated by history or physical examination.

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Imaging Studies

Chest radiography

Chest radiography usually (although not invariably) reveals a pneumomediastinum. Chest radiography reveals air within the mediastinal space. Coexisting disease (eg, pneumothorax, pneumoperitoneum, pneumoretroperitoneum of pneumopericardium) may also be evident.

Radiolucent streaks representing free air may be observed tracking along the margins of the heart, within the retrosternal space, or surrounding the trachea. Typical features of pneumomediastinum seen on chest radiography are caused by air outlining normal anatomic structures as it tracks from the mediastinum producing the thymic sail sign, "ring around the artery" sign, tubular artery sign, double bronchial wall sign, continuous diaphragm sign, and the extrapleural sign (see the image below, which is a chest radiograph demonstrating pneumomediastinum as well as subcutaneous emphysema in a female with asthma intubated for respiratory failure).

The chest radiograph is taken from an adolescent gThe 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.
  • Ring around the artery (tubular artery): A radiolucent area is observed surrounding the right pulmonary artery when viewed on a lateral chest radiograph.
  • Thymic sail sign: In infants with pneumomediastinum, the thymic lobes are shifted upwards resembling a full sail.
  • Continuous diaphragm sign: Free air is present between the pericardium and diaphragm, causing the central parts of the diaphragm to become apparent.

Chest CT scanning

Chest CT scanning has 2 major roles in the diagnosis of pneumomediastinum.

Chest CT scanning may be used to diagnose pneumomediastinum not visualized on chest radiography. A study from Japan describes the use of chest CT scanning in diagnosing small pneumomediastinum not visible on chest radiography. In a series of 33 patients diagnosed with spontaneous pneumomediastinum (SPM) on the basis of clinical presentation and/or chest radiography findings, chest CT scanning revealed pneumomediastinum in 3 patients in whom the chest radiography findings were unremarkable. The authors concluded that chest radiography alone may result in a missed diagnosis in 10% of patients presenting with pneumomediastinum. Fujiwara reported that pneumomediastinum was found in 15% of patients with idiopathic pulmonary fibrosis.[22]

Ho et al[23] report a series comparing the radiologic findings of patients diagnosed with spontaneous pneumomediastinum to those with secondary pneumomediastinum associated with a central airways defect, esophageal rupture, or recent intervention in the airway or esophagus. They note that on multidetector CT (MDCT), spontaneous pneumomediastinum patients were more likely to have air in the anterior mediastinum (97% vs 61%, P < .001) and pulmonary interstitial emphysema (57% vs 4%, P < .001) and less likely to show subdiaphragmatic air (0% vs 32%, P < .001), pleural effusions (9% vs 61%, P < .001), and acute pulmonary airspace opacities (14% vs 50%, P = .003) when compared with patients with secondary pneumomediastinum.

CT scanning may provide additional diagnostic information regarding the presence of coexisting illness, such as perforated esophagus. Dissanaike et al noted that major injuries to the aerodigestive tract were readily identified on chest CT scans performed in adult patients with blunt trauma and pneumomediastinum.[24]

Contrast radiography

In cases of suspected esophageal perforation, contrast studies are mandatory. Some authors recommend the use of a water-soluble contrast agent followed by a barium meal if the findings are normal, in order to increase the sensitivity of the test.

MRI

The routine use of MRI in the diagnostic evaluation of pneumomediastinum has not been reported. However, Castellote et al reports the sensitivity of MRI in detection of free air as well as other forms of intrathoracic pathology.[25]

Ultrasonography

Megremis et al details the use of ultrasonography in the detection of pneumomediastinum.[26]

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Other Tests

Spirometry

Spirometry or measurements of peak expiratory flow should not be undertaken in patients with pneumomediastinum because the increased alveolar pressures may further exacerbate the air leak.

Electrocardiography

An ECG may be performed to evaluate for myocardial infarction, pericarditis, and myocarditis. Decreased voltage, ST segment depression, and nonspecific T-wave changes may be noted as indications of these potential disease processes.

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Procedures

Diagnostic or therapeutic procedures are generally not necessary. Placement of a chest tube should not be attempted unless an accompanying symptomatic pneumothorax is present.

Bronchoscopy is indicated if a tracheobronchial perforation is suspected, which may occasionally be observed following blunt chest trauma. Neal et al observed that pneumomediastinum after blunt trauma in clinically stable children is rarely associated with significant underlying injury to the tracheobronchial tree.[27] In addition to trauma indications, bronchoscopy may assist with localization and removal of foreign bodies as well as the evaluation of endobronchial lesions that may occur in association with pneumomediastinum.[28]

Haam et al report a series in which all patients with spontaneous pneumomediastinum undergoing contrast studies of the esophagus or esophagoscopy had normal studies.[29] These authors suggest that these studies are indicated only if an esophageal perforation is suspected or signs of mediastinitis are present.

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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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