Pneumomediastinum Follow-up

Updated: Feb 26, 2019
  • Author: Patrick L Carolan, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Follow-up

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). [44]

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.

A retrospective study characterized the outcomes of pediatric spontaneous pneumomediastinum and proposed a management pathway. In a series of 96 pediatric patients, it was noted that 92% of patients with PM were hospitalized. Length of stay for non-ICU patients was 1 day, and 3 days for ICU admissions. Follow-up imaging was obtained in 81% of patients but did not alter management decision-making. The study concluded that spontaneous pneumomediastinum without associated comorbidities can be managed with expectant outpatient observation without further imaging. Children with asthma should be treated independent of spontaneous pneumomediastinum. [45]

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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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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 wind 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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