Air Dissection Research Articles

Congenital diaphragmatic hernia: Deleterious effects of pulmonary interstitial emphysema and tension extrapulmonary air

Survival after repair of congenital diaphragmatic hernia (CDH) is limited by adequacy of prenatal pulmonary development. Ventilatory function may be compromised further by multiple adverse perinatal factors that necessitate intermittent pressure ventilation (IPPV). Barotrauma frequently complicates IPPV, and is observed in several forms. These complications lead to ventilatory and hemodynamic dysfunctions. Of 50 infants with CDH repaired in the first 24 hr of life, 36% survived. Infants operated in the first 8 hr had a lower survival rate (28%) than those operated between 8 and 24 hr (50%). Tension extrapulmonary air (TEPA) was observed in 30 infants (60%), was significantly higher in dying infants ( p p

The role of air dissection in bronchopulmonary dysplasia

The role of air dissection in bronchopulmonary dysplasia

Persistent Localized Pulmonary Interstitial Emphysema and Lymphangiectasia: A Causal Relationship?

The mechanism responsible for persistent regional pulmonary interstitial emphysema under tension, which occasionally complicates assisted ventilation, has not been explained. It is difficult to comprehend how interstitial air may cause lobar hyperinflation and not escape to the mediastinum or pleura. Histologic examination of resected emphysematous lung in two neonates with this type of interstitial emphysema revealed air dissecting from the interstitial connective tissue into markedly dilated lymphatics. It is proposed that intralymphatic air dissection causing emphysematous lymphangiectasia may be responsible for fixation of the lung in the emphysematous state.

Computerized tomography of frontal sinus pneumatocele

The radiographic feature and computerized tomography (CT) findings in a case of frontal sinus osteoma associated with pneumatocele are described along with the clinical history and surgical findings. CT gives useful information regarding the extent of air dissection and its relation with the ventricular system.

Evacuation of pericardial, anterior mediastinal, and peripleural air collections in neonatal respiratory distress

Alveolar rupture in the neonate can result in the dissection of air along vascular sheaths and the formation of abnormal collections within the mediastinal, pleural, pericardial, or peripleural spaces or elsewhere. Intercostal tube placement for pneumothorax is frequently required. A method is presented for the placement of Intracath catheters into pericardial, anterior mediastinal, and peripleural collections of air when other adjustments in treatment have not allevaited clinical distress.

Pneumoperitoneum Complicating Mechanical Ventilator Therapy

Subdiaphragmatic air arouses the clinical suspicion of a perforated intra-abdominal viscus. In patients with respiratory failure requiring mechanical ventilation, the retroperitoneal dissection of air from the mediastinum may give rise to radiologic evidence of subdiaphragmatic emphysema. The present report describes four patients with this syndrome. In three of them, a perforated gastric or duodenal ulcer was initially suspected. None of these three patients underwent surgery. Autopsy examinations in two patients revealed extraperitoneal subdiaphragmatic emphysema with secondary rupture into the free peritoneal cavity. The third patient had an uneventful recovery and was discharged from the hospital. In a fourth patient, signs of peritonitis prompted an exploratory laparotomy. No perforation of an intraperitoneal viscus was identified. Upper gastrointestinal contrast roentgenography and peritoneal lavage may help determine the etiology of subdiaphragmatic air in patients undergoing therapy with a mechanical ventilator.

Pneumatosis Intestinalis After Jejunoileal Bypass

JEJUNOILEAL bypass for gross, morbid obesity has become widely accepted during the past few years. As one would expect from an operation creating major perturbations in the anatomy and physiology of the alimentary tract, the price paid, in terms of undesirable side effects for the often spectacular results, has been high, albeit not prohibitively so. Among the unanticipated and apparently specific complications of this operation that have been discovered recently is that of pneumatosis intestinalis in the bypassed intestine. Two cases have been reported by Passaro et al¹and one by Martyak and Curtis.²All three cases were characterized by severe gaseous distension of the small bowel associated with subserosal air dissection and, in two instances, with pneumoperitoneum. One patient in our series has had this complication, and under circumstances that enabled us to understand the mechanism of its development. If our interpretation is correct, this complication should

Spontaneous subcutaneous emphysema of the head, neck, and mediastinum.

Spontaneous pneumomediastinum and cervical subcutaneous emphysema have been well documented. They occur as a result of increased alveolar pressure sufficient to cause rupture of the alveolar wall and dissection of air along interstitial spaces to the mediastinum and thence along fascial planes to the neck. Occurrence has been reported with asthma, measles, laryngotracheobronchitis, and isolated Valsalva maneuvers. The condition is generally benign and self-limiting and usually requires treatment only for the primary respiratory disease. However, there may be life-threatening complications that require specific surgical management. These patients should be followed closely so that sequelae may be recognized early and appropriate treatment instituted.

Interstitial pulmonary emphysema in children and adults: roentgenographic features.

Chest films of 12 patients ranging in age from 3 to 55 years with autopsy-verified interstitial pulmonary emphysema (IPE) were reviewed. All had received positive pressure breathing. Opacification of the lungs due to edema, hemorrhage, or pneumonia often made IPE visualization possible. Diagnostic radiographic features include direct visualization of interstitial air, and the appearance of subpleural air cysts formed by continued dissection of interstitial air into the subpleural connective tissues. Recognition of IPE is of importance because it may directly impair pulmonary ventilation and perfusion and may be followed by development of pneumomediastinum, pneumothorax, and secondary infection.

Unusual causes of small-bowel pneumatosis: perforated duodenal ulcer and perforated jejunal diverticula.

Two unusual cases of pneumatosis of the small bowel associated with pneumoperitoneum are reported. In one patient, a perforated duodenal ulcer was seen with extensive pneumatosis of the jejunum, a pattern diagnostic of bowel infarction. In the other, perforated jejunal diverticula were seen with pneumatosis of a jejunal loop and a large pneumoperitoneum, but there were only mild abdominal symptoms. In both cases, the most likely cause was subserosal dissection of air from the site of the perforation.

Rapid tracheal injury by cuffed airways and healing with loss of ciliated epithelium.

In 54 patients examined at autopsy, the acute tracheal erosions produced by two types of commercially available endotracheal tubes with inflatable cuffs were similar to those induced by two types of cuffed tracheostomy tubes. The erosions exposed portions of the tracheal cartilages within 12 to 48 hours. Healing of the circumferential tracheal erosions often was accompanied by the loss of the submucosal mixed mucous and serous glands and the replacement of the normal ciliated epithelium by stratified squamous epithelium. Such a zone in a long-term survivor may become a substantial barrier to removal of particulate matter from the tracheobronchial tree. Additional complications of controlled ventilation included mediastinal and subcutaneous air dissection, tension pneumothorax, perforation of the esophagus, bronchial obstruction, hemorrhage, and signs suggestive of adult oxygen toxicity. Hemorrhage appeared to be more common in patients receiving anticoagulants.

SMALL-INTESTINAL INTRAMURAL AIR.

Linear, radiolucent, localized contour shadows within the walls of distended small-intestinal loops have been overlooked and undervalued. These intramural air stripes may sometimes be the only roentgen sign of impending perforation in cases of mechanical ileus or of bowel necrosis. A search for such intramural lines hidden in the simple scout abdominal roentgenogram is imperative, for their presence should alert the radiologist to the gravity of the situation and thus influence the immediate surgical decision and approach. In no other abdominal condition is the patient in such immediate danger as in gangrene of the small intestine. The purpose of this paper is to emphasize that intramural air in cases of obstructive ileus is indicative of necrosis and∕or impending perforation. Case I: S.A. was a male infant aged thirty days, with a clinical diagnosis of peritonitis as a result of volvulus of the small intestine (due to malrotation?). A roentgenogram of the abdomen (Fig. 1) with the patient in the supine position was obtained twenty-four hours prior to death. Ring-like and polycyclic radiolucent shadows, characteristic of gas (arrows), were shown, parallel to the outer margins of the dilated small-intestinal loops. Similar areas of increased radiability radiated in a linear, vascular pattern to the periphery of the liver area (arrows); these were interpreted as gas in the portal veins. No separation of loops or evidence of pneumoperitoneum was seen in the upright position. The fixed, crescent-like continuous lines of increased radiability suggested that dissection of air had taken place intramurally along the small-intestinal wall. In addition, the gas in the portal veins suggested that gangrene or severe infection of the intestinal loops was present. Autopsy revealed hemopneumoperitoneum; malrotation of the intestine (incomplete rotation, cecum mobile) with torsion of the mesentery and volvulus; hemorrhagic infarction and necrosis of the mesentery and the intestine; ileus; air bleb formations in the subserous portion of the intestine; fibrinous peritonitis. The liver weighed 150 gm. Unfortunately, no negative or positive statement was made regarding the air in the liver vessels. No blood or intestinal cultures were taken. Case II: Sh. L. was a 50-year-old woman. A roentgenogram of the abdomen (Fig. 2), with the patient in supine position showed markedly dilated intestinal loops and short, crescent-like radiolucent lines parallel to the outer border of the upper bowel in two areas (arrows). Although pneumoperitoneum was present, the localization of radiolucent lines, overlying and following the small intestinal margins, suggested intramural air dissection. At operation, gangrenous, foul-smelling, black, small-intestinal loops were encountered, due to an incarcerated inguinal hernia. A hole of 2 sq. cm. was found at the strangulation point.

Case reports. Intramural gastric emphysema.

Gastric emphysema is characterised by air dissection within the wall of the stomach. The few cases which have been reported in the literature occurred following gastroscopy, emphysematous gastritis and pneumatosis cystoides intestinalis. The present communication deals with a case of intramural gastric emphysema which developed following over-distension of the stomach due to obstruction of the duodenum by an impacted gall-stone. Review of the literature has failed to disclose such an occurrence. A 75-year-old female was admitted to the emergency ward because of severe intractable vomiting for three days. The past history revealed that the patient had some minor “indigestion”. Three weeks prior to her admission an X-ray examination of the stomach and duodenal bulb had not revealed any pathology. The stomach was normal in size and shape. On admission the patient was dehydrated but not undernourished. The abdomen was not markedly distended, no resistance was palpated, no signs of any peritoneal irritation we...

Spontaneous rupture of the esophagus, with report of five cases.

Spontaneous rupture of the esophagus is a rare condition, which until recently carried a grave prognosis. Whereas most cases reported up to 1944 had terminated fatally, there have been, as a result of improved methods of diagnosis and treatment, 16 survivals among 40 cases published during the last six years. Including the 5 examples to be presented here, the world literature contains records of 92 cases, 32 of which have been reported since 1947. So far as we are aware, a single case, that of Aldrich and Anspach (1), is to be found in the radiological literature. Adequate bibliographies are furnished by Barrett (2), Kinsella et al. (29), and Lynch (35). The original description of spontaneous rupture of the esophagus is said by McWeeney (42) to be that of Boerhaave in 1724. The first antemortem diagnosis is credited to Walker in 1924 (56). At present the diagnosis is based upon the patient's history, the clinical findings, and confirmatory roentgenograms. We shall endeavor here to summarize the known facts concerning this condition, with particular emphasis on the roentgen diagnosis. By spontaneous rupture is meant a complete tear involving all layers of the wall of a previously normal esophagus. This excludes incomplete tears and rupture at the site of neoplasm, peptic ulcer, corrosive esophagitis, other forms of esophageal inflammation, aneurysms, perforation from instrumentation, biopsy, or trauma following foreign bodies. Four incomplete tears involving the muscle and mucosal layer at the lower end of the esophagus were found postmortem by Weiss and Mallory (60). Spontaneous rupture of the esophagus occurs usually in middle-aged individuals; it is rare in children though it has been reported (38). Eighty-four per cent of the patients have been males (29). Additional information based on the collected cases is presented in Graph I. Mechanism of Rupture Spontaneous rupture of the esophagus is explained by most authors on the basis of sudden increase in intra-abdominal pressure due to vomiting, retching, or convulsions. The pressure is believed to be transmitted to the esophagus as a consequence of associated pylorospasm and spasm of the cricopharyngeus muscles, resulting in a tear of the lower third. The stomach contents, including air, then dissect upward along the fascial plane of the mediastinum. The air will often invade the neck. The close relationship of the left pleura to the mediastinal portion of the tear in the lower third of the esophagus explains the frequent association of left-sided hydropneumothorax. Surprisingly, no free air has ever been found within the pericardium or abdominal cavity. Mallory (60) and Barrett (2) reported the only cases showing dissection of air retroperitoneally postmortem. The following may aid in explaining rupture of a previously normal esophagus.

Traumatic Pneumocephalus

Prior to the advent of radiologic diagnosis, only one case of traumatic pneumocephalus had been reported. Extracranial pneumatocele, characterized by the dissection of air through the subaponeurotic tissues of the scalp, has long been recognized, but its intracranial counterpart, following fracture of the paranasal sinuses or mastoids, was not so accessible to the usual methods of diagnosis. Since the report of Luckett in 1913, many cases of pneumocephalus have been recorded, and major contributions such as those of Dandy and Lewis have appeared. The following case presents evidence of the immediate development of pneumocephalus following skull fracture, a somewhat unusual finding. A well developed white male was attacked by thieves as he stopped to change a tire early in the morning of April 10, 1948. He evidently was struck about the head and face by some blunt object. He was found unconscious on the street shortly after the beating and was brought immediately to Wesley Memorial Hospital. Films of the skull and facial bones taken probably four or five hours after injury were not entirely satisfactory because of the patient's disoriented condition. They revealed, however, various linear fractures in the vault, chiefly on the left, with multiple fracture lines entering the base of the skull in the region of the sphenoid yoke and the cribriform plate. Fracture of the lateral wall of the right maxillary sinus, with dense clouding of this sinus, was also observed. A large amount of air was seen within the subarachnoid space, both in the basal cisterns and surrounding the cerebral convexities. The lateral ventricles were well delineated by air (Fig. 1). Air was also present in the subdural space about the falx (Fig. 2). Physical examination on entry to the hospital showed edema and ecchymosis of the periorbital tissues. The left pupil was larger than the right, and there was no evidence of light perception by the left eye. A large hematoma was present over the left temporal bone, and there were a few small lacerations, the largest involving the left ear. Dry blood was seen in the nasal cavity, but no cerebrospinal fluid rhinorrhea or otorrhea was observed at this time. There were no cranial nerve motor changes, and generally the reflexes were normal; no signs of meningeal irritation were present. Blood pressure was 130/78. Laboratory findings were not significant. By April 11 the patient was fully conscious. He received penicillin and sulfonamides from the time of admission to April 18. Parenteral fluids were discontinued after the first two days, after which time he took nourishment by mouth. The blood pressure ranged from 120 to 140 systolic and from 68 to 90 diastolic. The temperature, which rose to 103° F. on April 12, subsided rapidly and remained under 99.4° to the time of discharge. Ophthalmologic examination on April 14 revealed complete blindness of the left eye, and it was concluded that the left optic nerve had been severed.