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.^[51]

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.^[52]CT-guided placement may also be considered.

Diet

No special diet is indicated.

Activity

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

Medication

Gasser CR, Pellaton R, Rochat CP. Pediatric Spontaneous Pneumomediastinum: Narrative Literature Review. Pediatr Emerg Care. 2016 Feb 6. [QxMD MEDLINE Link].
Jennings S, Peeceeyen S, Horton M. Tension pneumomediastinum after blunt chest trauma. ANZ J Surg. 2013 Oct 31. [QxMD MEDLINE Link].
Zylak CM, Standen JR, Barnes GR, Zylak CJ. Pneumomediastinum revisited. Radiographics. 2000 Jul-Aug. 20(4):1043-57. [QxMD MEDLINE Link]. [Full Text].
Carolan PL, Wright SL, Jha V. Spontaneous pneumorrhachis. Pediatr Emerg Care. 2013 Apr. 29(4):508-9. [QxMD MEDLINE Link].
Behr G, Mema E, Costa K, Garg A. Proportion and Clinical Relevance of Intraspinal Air in Patients With Pneumomediastinum. AJR Am J Roentgenol. 2018 Aug. 211 (2):321-326. [QxMD MEDLINE Link].
Liu YW, Kao CN, Wang YM. Pneumorrhachis: an under-recognized entity correlates with severity of spontaneous pneumomediastinum. J Thorac Dis. 2018 Feb. 10 (2):E149-E151. [QxMD MEDLINE Link].
Wong KS, Wu HM, Lai SH, Chiu CY. Spontaneous pneumomediastinum: analysis of 87 pediatric patients. Pediatr Emerg Care. 2013 Sep. 29(9):988-91. [QxMD MEDLINE Link].
Gasser CR, Pellaton R, Rochat CP. Pediatric Spontaneous Pneumomediastinum: Narrative Literature Review. Pediatr Emerg Care. 2017 May. 33 (5):370-374. [QxMD MEDLINE Link].
Jones R, Kundrotas L. "HOOAH!" A case of pneumomediastinum in the military training environment; Hamman's sign 71 years later. Mil Med. 2011 Mar. 176(3):352-5. [QxMD MEDLINE Link].
Sadarangani S, Patel DR, Pejka S. Spontaneous pneumomediastinum and epidural pneumatosis in an adolescent precipitated by weight lifting: a case report and review. Phys Sportsmed. 2009 Dec. 37(4):147-53. [QxMD MEDLINE Link].
Vazquez JL, Vazquez I, Gonzalez ML, Garcia-Tejedor JL, Reparaz A. Pneumomediastinum and pneumothorax as presenting signs in severe Mycoplasma pneumoniae pneumonia. Pediatr Radiol. 2007 Dec. 37(12):1286-8. [QxMD MEDLINE Link].
Megremis S, Stefanaki S, Tsekoura T, Tsilimigaki A. Spontaneous pneumomediastinum in a child: sonographic detection in a case with minimal findings on chest radiography. J Ultrasound Med. 2008 Feb. 27(2):303-6. [QxMD MEDLINE Link].
Lin HW, Kakarala K, Ostrower ST, Leonard DS. Laryngotracheobronchitis complicated by spontaneous pneumomediastinum. Int J Pediatr Otorhinolaryngol. 2010 Feb. 74(2):221-4. [QxMD MEDLINE Link].
Hasegawa M, Hashimoto K, Morozumi M, Ubukata K, Takahashi T, Inamo Y. Spontaneous pneumomediastinum complicating pneumonia in children infected with the 2009 pandemic influenza A (H1N1) virus. Clin Microbiol Infect. 2010 Feb. 16(2):195-9. [QxMD MEDLINE Link].
Elhakim TS, Abdul HS, Pelaez Romero C, Rodriguez-Fuentes Y. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review. BMJ Case Rep. 2020 Dec 12. 13 (12):[QxMD MEDLINE Link]. [Full Text].
Zhou C, Gao C, Xie Y, Xu M. COVID-19 with spontaneous pneumomediastinum. Lancet Infect Dis. 2020 Apr. 20 (4):510. [QxMD MEDLINE Link]. [Full Text].
Rezende-Neto JB, Hoffmann J, Al Mahroos M, Tien H, Hsee LC, Spencer Netto F, et al. Occult pneumomediastinum in blunt chest trauma: clinical significance. Injury. 2010 Jan. 41(1):40-3. [QxMD MEDLINE Link].
Chalumeau M, Le Clainche L, Sayeg N, et al. Spontaneous pneumomediastinum in children. Pediatr Pulmonol. 2001 Jan. 31(1):67-75. [QxMD MEDLINE Link].
Stack AM, Caputo GL. Pneumomediastinum in childhood asthma. Pediatr Emerg Care. 1996 Apr. 12(2):98-101. [QxMD MEDLINE Link].
Vianello A, Caminati M, Chieco-Bianchi F, Marchi MR, Vio S, Arcaro G, et al. Spontaneous pneumomediastinum complicating severe acute asthma exacerbation in adult patients. J Asthma. 2017 Oct 9. 1-7. [QxMD MEDLINE Link].
Weg JG, Anzueto A, Balk RA, et al. The relation of pneumothorax and other air leaks to mortality in the acute respiratory distress syndrome. N Engl J Med. 1998 Feb 5. 338(6):341-6. [QxMD MEDLINE Link].
Muckart DJJ, Hardcastle TC, Skinner DL. Pneumomediastinum and pneumopericardium following blunt thoracic trauma: much ado about nothing?. Eur J Trauma Emerg Surg. 2018 Apr 23. [QxMD MEDLINE Link].
Briassoulis GC, Venkataraman ST, Vasilopoulos AG, et al. Air leaks from the respiratory tract in mechanically ventilated children with severe respiratory disease. Pediatr Pulmonol. 2000 Feb. 29(2):127-34. [QxMD MEDLINE Link].
Esayag Y, Furer V, Izbicki G. Spontaneous pneumomediastinum: is a chest X-ray enough? A single-center case series. Isr Med Assoc J. 2008 Aug-Sep. 10(8-9):575-8. [QxMD MEDLINE Link].
Lee CY, Wu CC, Lin CY. Etiologies of spontaneous pneumomediastinum in children of different ages. Pediatr Neonatol. 2009 Oct. 50(5):190-5. [QxMD MEDLINE Link].
Damore DT, Dayan PS. Medical causes of pneumomediastinum in children. Clin Pediatr (Phila). 2001 Feb. 40(2):87-91. [QxMD MEDLINE Link].
MacKnight JM, Mistry DJ. Chest Pain in the Athlete: Differential Diagnosis, Evaluation, and Treatment. Lawless CE. Sports Cardiology Essentials. New York: Springer; 2011. 115-140.
Kim KS, Jeon HW, Moon Y, Kim YD, Ahn MI, Park JK, et al. Clinical experience of spontaneous pneumomediastinum: diagnosis and treatment. J Thorac Dis. 2015 Oct. 7 (10):1817-24. [QxMD MEDLINE Link].
Majerus CR, Tredway TL, Yun NK, Gerard JM. Utility of Chest Radiographs in Children Presenting to a Pediatric Emergency Department With Acute Asthma Exacerbation and Chest Pain. Pediatr Emerg Care. 2018 Sep 25. [QxMD MEDLINE Link].
Okada M, Adachi H, Shibuya Y, Ishikawa S, Hamabe Y. Diagnosis and treatment of patients with spontaneous pneumomediastinum. Respir Investig. 2014 Jan. 52(1):36-40. [QxMD MEDLINE Link].
Walsh-Kelly C, Kelly KJ. Dysphonia: an unusual presentation of spontaneous pneumomediastinum. Pediatr Emerg Care. 1986 Mar. 2(1):26-7. [QxMD MEDLINE Link].
Huon LK, Chang YL, Wang PC, Chen PY. Head and neck manifestations of spontaneous pneumomediastinum. Otolaryngol Head Neck Surg. 2012 Jan. 146(1):53-7. [QxMD MEDLINE Link].
Chalumeau M, Le Clainche L, Sayeg N, et al. Spontaneous pneumomediastinum in children. Pediatr Pulmonol. 2001 Jan. 31(1):67-75. [QxMD MEDLINE Link].
Hochlehnert A, Löwe B, Bludau HB, Borst M, Zipfel S, Herzog W. Spontaneous pneumomediastinum in anorexia nervosa: a case report and review of the literature on pneumomediastinum and pneumothorax. Eur Eat Disord Rev. 2010 Mar. 18(2):107-15. [QxMD MEDLINE Link].
Makdsi F, Kolade VO. Diabetic ketoacidosis with pneumomediastinum: a case report. Cases J. 2009 Sep 9. 2:8095. [QxMD MEDLINE Link]. [Full Text].
Kouki S, Fares AA. Postpartum spontaneous pneumomediastinum 'Hamman's syndrome'. BMJ Case Rep. 2013 Sep 3. 2013:[QxMD MEDLINE Link].
Perna V, Vilà E, Guelbenzu JJ, Amat I. Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients. Eur J Cardiothorac Surg. 2010 Mar. 37(3):573-5. [QxMD MEDLINE Link].
Sahni S, Verma S, Grullon J, Esquire A, Patel P, Talwar A. Spontaneous Pneumomediastinum: Time for Consensus. N Am J Med Sci. 2013 Aug. 5(8):460-464. [QxMD MEDLINE Link]. [Full Text].
Banki F, Estrera AL, Harrison RG, Miller CC 3rd, Leake SS, Mitchell KG, et al. Pneumomediastinum: etiology and a guide to diagnosis and treatment. Am J Surg. 2013 Dec. 206(6):1001-6. [QxMD MEDLINE Link].
Vanden Berghe S, Devlies F, Seynaeve P. The Spinnaker-Sail Sign: Neonatal Pneumomediastinum. J Belg Soc Radiol. 2018 Aug 7. 102 (1):51. [QxMD MEDLINE Link].
Popik E, Barroso F, Domingues S, Araújo LN, Carvalho C, Fonte M. Spontaneous neonatal pneumomediastinum and spinnaker-sail sign. J Paediatr Child Health. 2018 Nov. 54 (11):1273. [QxMD MEDLINE Link].
Ho AS, Ahmed A, Huang JS, Menias CO, Bhalla S. Multidetector Computed Tomography of Spontaneous Versus Secondary Pneumomediastinum in 89 Patients: Can Multidetector Computed Tomography be Used to Reliably Distinguish Between the 2 Entities?. J Thorac Imaging. 2012 Mar. 27(2):85-92. [QxMD MEDLINE Link].
Dissanaike S, Shalhub S, Jurkovich GJ. The evaluation of pneumomediastinum in blunt trauma patients. J Trauma. 2008 Dec. 65(6):1340-5. [QxMD MEDLINE Link].
Lee WS, Chong VE, Victorino GP. Computed Tomographic Findings and Mortality in Patients With Pneumomediastinum From Blunt Trauma. JAMA Surg. 2015 Aug. 150 (8):757-62. [QxMD MEDLINE Link].
Wu CH, Chen CM, Chen CC, Wong YC, Wang CJ, Lo WC, et al. Esophagography after pneumomediastinum without CT findings of esophageal perforation: is it necessary?. AJR Am J Roentgenol. 2013 Nov. 201(5):977-84. [QxMD MEDLINE Link].
Castellote A, Vazquez E, Vera J, et al. Cervicothoracic lesions in infants and children. Radiographics. 1999 May-Jun. 19(3):583-600. [QxMD MEDLINE Link]. [Full Text].
Macia I, Moya J, Ramos R, et al. Spontaneous pneumomediastinum: 41 cases. Eur J Cardiothorac Surg. 2007 Jun. 31(6):1110-4. [QxMD MEDLINE Link].
Neal MD, Sippey M, Gaines BA, Hackam DJ. Presence of pneumomediastinum after blunt trauma in children: what does it really mean?. J Pediatr Surg. 2009 Jul. 44(7):1322-7. [QxMD MEDLINE Link].
Lee CY, Wu CC, Lin CY. Etiologies of spontaneous pneumomediastinum in children of different ages. Pediatr Neonatol. 2009 Oct. 50(5):190-5. [QxMD MEDLINE Link].
Haam SJ, Lee JG, Kim DJ, Chung KY, Park IK. Oesophagography and oesophagoscopy are not necessary in patients with spontaneous pneumomediastinum. Emerg Med J. 2010 Jan. 27(1):29-31. [QxMD MEDLINE Link].
Cunningham LC, Jatana KR, Grischkan JM. Conservative management of iatrogenic membranous tracheal wall injury: a discussion of 2 successful pediatric cases. JAMA Otolaryngol Head Neck Surg. 2013 Apr. 139(4):405-10. [QxMD MEDLINE Link].
Chau HH, Kwok PC, Lai AK, et al. Percutaneous relief of tension pneumomediastinum in a child. Cardiovasc Intervent Radiol. 2003 Nov-Dec. 26(6):561-3. [QxMD MEDLINE Link].
[Guideline] Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. Bethesda (MD): Global Initiative for Asthma (GINA); 2008.
Fitzwater JW, Silva NN, Knight CG, Malvezzi L, Ramos-Irizarry C, Burnweit CA. Management of spontaneous pneumomediastinum in children. J Pediatr Surg. 2015 Jun. 50(6):983-6. [QxMD MEDLINE Link].
Bagga B, Kumar A, Chahal A, Gamanagatti S, Kumar S. Traumatic Airway Injuries: Role of Imaging. Curr Probl Diagn Radiol. 2018 Oct 29. [QxMD MEDLINE Link].
Ehmann MR, Paziana K, Stolbach AI. Case Series: Pneumorrhachis Secondary to Spontaneous Pneumomediastinum. J Emerg Med. 2016 Feb. 50 (2):e43-5. [QxMD MEDLINE Link].

Media Gallery

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.

of 5

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, 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.

Acknowledgements

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.