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). [53]
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. [54]
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.
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.
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.
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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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.
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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.
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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.
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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.
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Subcutaneous emphysema and pneumothorax.
