Pneumomediastinum Treatment & Management

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

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 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. [42]

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. [43] 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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