PneumomediastinumPneumomediastinum

Tyler BagleyTyler Bagley

October 17, 2006October 17, 2006

ObjectivesObjectives

1. Recognize the causes of 1. Recognize the causes of pneumomediastinumpneumomediastinum

2. Recognize the presentation2. Recognize the presentation 3. Identify common radiological signs3. Identify common radiological signs 4. Discuss when to order additional tests4. Discuss when to order additional tests 5. Treatment5. Treatment

Pulmonary Causes:Pulmonary Causes:

Rupture of the alveolus with air dissection Rupture of the alveolus with air dissection along the peribronchial vascular sheaths into along the peribronchial vascular sheaths into the hilum and mediastinumthe hilum and mediastinum

Ruptured bleb with peripheral extensionRuptured bleb with peripheral extension Sudden rise in intrapulmonary pressureSudden rise in intrapulmonary pressure

Asthma, vomiting, forceful coughing, crying, Asthma, vomiting, forceful coughing, crying, shouting, Valsalva maneuver, artificial ventilation, shouting, Valsalva maneuver, artificial ventilation, closed chest trauma, sudden drop in atmospheric closed chest trauma, sudden drop in atmospheric pressure, foreign body aspirationpressure, foreign body aspiration

TraumaTrauma

Rupture of trachea or mainstem Rupture of trachea or mainstem bronchus, usually via accidental traumabronchus, usually via accidental trauma

Trauma to the neck Trauma to the neck Boerhaave’s SyndromeBoerhaave’s Syndrome BarotraumaBarotrauma

Mediastinum ConnectionsMediastinum Connections

The mediastinum communicates with the The mediastinum communicates with the submandibular space, retropharyngeal submandibular space, retropharyngeal space and vascular sheaths within the space and vascular sheaths within the neckneck

Also can communicate with the Also can communicate with the retroperitoneum via sternocostal retroperitoneum via sternocostal attachments to the diaphragm, as well as attachments to the diaphragm, as well as the periaortic and periesophageal fascial the periaortic and periesophageal fascial planesplanes

PresentationPresentation

Infants-typically noneInfants-typically none Adults- Adults-

May complain of retrosternal chest pain radiating May complain of retrosternal chest pain radiating down both arms that is exacerbated by respiration down both arms that is exacerbated by respiration and swallowingand swallowing

Dyspnea-in association with asthma, tension PM or Dyspnea-in association with asthma, tension PM or pneumothoraxpneumothorax

Fever-due to cytokine release with an air leakFever-due to cytokine release with an air leak Throat or jaw pain, dysphonia, dysphagia, neck Throat or jaw pain, dysphonia, dysphagia, neck

swelling and torticollisswelling and torticollis

Physical ExamPhysical Exam

Subcutaneous AirSubcutaneous Air Associated PneumothoraxAssociated Pneumothorax Oxygen SaturationsOxygen Saturations Hamman’s Sign- Hamman’s Sign-

““Crunching” sound heard over the apex of Crunching” sound heard over the apex of the heart with the cardiac cyclethe heart with the cardiac cycle

Linear density parallel to Linear density parallel to the heart borderthe heart border

Extrapleural SignExtrapleural Sign

Air from the Air from the mediastinum can mediastinum can extend laterally extend laterally between the parietal between the parietal pleura and the pleura and the diaphragm to diaphragm to produce the produce the extrapleural sign extrapleural sign

Double Bronchial SignDouble Bronchial Sign

Air in the Air in the mediastinum and left mediastinum and left main bronchus main bronchus allows visualization allows visualization of both sides of the of both sides of the bronchial wall.bronchial wall.

Spinnaker Sign (Thymic Spinnaker Sign (Thymic Sail Sign)Sail Sign)

With sufficient mediastinal air, the thymus can become elevated, creating the Thymic Sail Sign, or Spinnaker Sign.

Newborn Newborn PneumomediastinumPneumomediastinum

Air in Anterior Air in Anterior MediastinumMediastinum

Tubular Artery SignTubular Artery Sign

Continuous Diaphragm Continuous Diaphragm SignSign

Ring around the Artery Ring around the Artery SignSign

Chest CTChest CT

Diagnostic ProceduresDiagnostic Procedures

Chest tube in coexisting pneumothoraxChest tube in coexisting pneumothorax Bronchoscopy if tracheobronchial Bronchoscopy if tracheobronchial

perforation is suspectedperforation is suspected Esophagoscopy if an esophageal Esophagoscopy if an esophageal

perforation is suspectedperforation is suspected

TreatmentTreatment

Mechanical ventilation with low pressure Mechanical ventilation with low pressure or tidal volumesor tidal volumes

Mediastinoscopy to alleviate life-Mediastinoscopy to alleviate life-threatening pneumomediastinumthreatening pneumomediastinum

Percutaneous placement of mediastinal Percutaneous placement of mediastinal drainsdrains

The End.