Management Of Pneumomediastinum Research Articles

Occult Pneumomediastinum - An Atypical Presentation of Chest Discomfort in a Patient with Depression

Pneumomediastinum (mediastinal emphysema) is an uncommon condition characterized by the accumulation of air or gas in the mediastinum. Here is a case of a 16-year-old female known to have depression who presented to the emergency department with complaints of shortness of breath, restlessness, chest discomfort, and hoarseness of voice for 2 days. She was initially diagnosed with panic attack, and later on clinical examination, surgical emphysema over the right supraclavicular area was noticed. Chest X-ray was found to be normal, and further imaging with high-resolution computed tomography (HRCT) of the thorax showed pneumomediastinum. In this report, the clinical presentations, radiological features, and management of pneumomediastinum will be discussed.

Presentation and management of pneumomediastinum in patients with COVID-19 infection

Pneumomediastinum, characterized by the presence of air in the mediastinum, can be primary (spontaneous) or secondary. Although relatively rare and usually benign with an incidence of 1 in 7,000 to 12,000 hospital admissions, some cases can develop hemodynamic instability due to mechanical pressure, reducing venous return and may require emergency surgery. Prior to the COVID-19 pandemic, reports of tension pneumomediastinum were infrequent, and there was no consensus on the best surgical approach to manage this condition. This review considers the diverse presentations, underlying causes, and diagnostic and operative approaches in patients with COVID-19 infection and pneumomediastinum. A systematic search of databases, including PubMed and Scopus, was conducted. Articles were reviewed to identify the risk factors for pneumomediastinum, the hemodynamic consequences, and approaches to management in both COVID-19 and non-COVID-19 cases. In patients with COVID-19 infection, pneumomediastinum represents a risk factor for poor outcomes, especially in patients requiring mechanical ventilation. In patients with tension pneumomediastinum, surgical release of mediastinal air is essential and can use suprasternal incisions, lateral sternal incisions, or sternotomy, all with drains. These patients are also at increased risk for tension pneumothorax and may require surgical chest tubes.
 
 Keywords: Pneumomediastinum, COVID-19, hemodynamics, surgical management, clinical challenges

LEAKY LUNGS: A COMPLICATION OF COVID-19 PNEUMONIA

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 pneumonia can result in complications such as ARDS, septic shock, thromboembolic events, and kidney failure. Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema are rare complications. CASE PRESENTATION: A 72-year-old African American female presented with a four day history of dyspnea. She was tachypneic with respiratory rate of 25/min with O2 saturation of 67% on room air, oxygen therapy via nonrebreather mask improved the O2 saturation to 92%. PCR test for SARS-CoV-2 was positive. Laboratory studies revealed a D-dimer-1121 ng/ml, C-reactive protein-15.97mg/dl, ferritin-356.8 and lactate dehydrogenase-337 U/L. Chest X-ray showed focal areas of interstitial and alveolar opacities. A CT scan of chest showed multiple focal ground glass opacities in the bilateral lung fields. She was treated with dexamethasone, remdesivir and supplemental oxygen. Two days later she became more hypoxic and chest X-ray showed increased interstitial opacities and a small pneumomediastinum. She was placed on high flow nasal cannula oxygen therapy. On the fourth day, her condition acutely worsened and she was emergently intubated without any complications and placed on mechanical ventilation with tidal volume of 6ml/kg ideal body weight. Post intubation chest-X-ray showed extensive pneumomediastinum, subcutaneous emphysema and right sided pneumothorax. Bilateral chest tubes were placed. Ultimately the patient passed away. DISCUSSION: COVID-19 pneumonia presents with a wide spectrum of symptoms, ranging from febrile illness to complications like ARDS, respiratory failure, and septic shock. Spontaneous pneumothorax, subcutaneous emphysema and pneumomediastinum are relatively rare complications. We presented a case of COVID-19 pneumonia who developed these complications while getting appropriate treatment. COVID-19 pneumonia can cause diffuse alveolar damage, desquamation of pneumocytes and cellular fibromyositis [1,2]. Increase in alveolar pressure by coughing or Valsalva maneuver can cause marginal alveoli to rupture and leak air into the interstitial space. The air then dissects between the perivascular and the peri-bronchial sheath into the mediastinum, pleural space and subcutaneous tissue causing pneumomediastinum, pneumothorax and subcutaneous emphysema respectively. Higher level of LDH is associated with increased risk of air leak from the lungs [3]. Small pneumothoraces can resolve on their own, but larger require chest tubes. Pneumomediastinum and subcutaneous emphysema are usually self-limiting benign conditions which resolve with bed rest, analgesics, and oxygen therapy [3]. CONCLUSIONS: Sudden deterioration in the oxygenation in COVID-19 patient should prompt clinicians to think of possible air leakage. Management of pneumomediastinum, subcutaneous emphysema and smaller spontaneous pneumothorax is conservative but large and tension pneumothoraces require chest tube. REFERENCE #1: Quincho-Lopez A, Quincho-Lopez DL, Hurtado-Medina FD. Case Report: Pneumothorax and Pneumomediastinum as Uncommon Complications of COVID-19 Pneumonia-Literature Review. Am J Trop Med Hyg. 2020;103(3):1170-1176. doi:10.4269/ajtmh.20-0815 REFERENCE #2: Shan S, Guangming L, Wei L, Xuedong Y. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19: case report and literature review. Rev Inst Med Trop Sao Paulo. 2020;62:e76. Published 2020 Oct 9. doi:10.1590/S1678-9946202062076 REFERENCE #3: 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;13(12):e239489. Published 2020 Dec 12. doi:10.1136/bcr-2020-239489 DISCLOSURES: No relevant relationships by Prakash Adhikari, source=Web Response No relevant relationships by Nikhil Madala, source=Web Response

UNUSUAL PRESENTATION OF PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA MIMICKING ANGIOEDEMA

SESSION TITLE: Case Report Semifinalists 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively safe technique associated with a very low complication rate for the sampling of mediastinal and hilar lymph nodes. Here we report a rare case of pneumomediastinum and subcutaneous emphysema following EBUS-TBNA. CASE PRESENTATION: 72 years old female, past smoker with remote history of right breast cancer s/p lumpectomy, radiation and chemotherapy (20 years ago), referred for evaluation of a 2.2 cm left hilar mass. She underwent elective EBUS under deep sedation after uneventful placement of a laryngeal mask airway, with transbronchial needle aspiration in the subcarinal (7) and left hilar stations (10L). There were no immediate complication. Two hours post procedure she developed rapidly progressive facial and neck swelling without any stridor. She was initially thought to have angioedema, and was intubated for airway compromise after she received IV Methylprednisolone 125 mg, IV epinephrine 10 mcg and 30 mcg subcutaneous epinephrine without improvement. No laryngeal edema was seen during intubation. Chest X ray subsequently showed extensive pneumomediastinum and subcutaneous emphysema. The decision was made to extubate patient since there was a risk of developing pneumothorax because of positive pressure. Patient was found to have air leak prior to extubation and was extubated to nasal cannula. Patient was discharged the next day to follow up as an outpatient. DISCUSSION: EBUS-TBNA is a safe procedure and complications are minimal. There are only a few case reports of pneumomediastinum associated with airway trauma from EBUS-TBNA so far. Subcutaneous emphysema may be observed in association with pneumomediastinum once pressure gradients allow air to spread via the fascial planes to the surrounding soft tissues [1]. Subcutaneous emphysema can mimic angioedema, an often a relatively benign disorder. Clinical presentations may include dramatic swelling of the neck associated with chest pain, wheezing, dyspnea, and dysphagia. Sparing of lips and presence of crepitus can be an important clue to differentiate it from angioedema [2]. Management of pneumomediastinum and sub cutaneous emphysema depends upon the clinical severity. Most patients respond well to the conservative management,however surgery may be required in rare cases. Treatment should be aimed at decreasing intrathoracic pressure spikes by reducing coughing and straining. CONCLUSIONS: Although EBUS-TBNA is considered a safe procedure with rare complications, it is necessary to remember that serious complications such as pneumomediastinum can occur. Our patient’s unusual presentation led to initial misdiagnosis. Although rare, clinicians must remain mindful of the complication to avoid delay in treatment. Reference #1: Ortiz, R., Hayes, M., Arias, S., Lee, H., Feller-Kopman, D. and Yarmus, L. (2014). Pneumomediastinum and Pneumopericardium after Endobronchial Ultrasound–Guided Transbronchial Needle Aspiration. Annals of the American Thoracic Society, 11(4), pp.680-681. Reference #2: Dhawan, A., Singal, A., Bisherwal, K., & Pandhi, D. (2016). Subcutaneous emphysema mimicking angioedema. Indian Dermatology Online Journal, 7(1), 55. https://doi.org/10.4103/2229-5178.174304 DISCLOSURES: No relevant relationships by Kulothungan Gunasekaran, source=Web Response No relevant relationships by Gini Priyadharshini Jeyashanmugaraja, source=Web Response No relevant relationships by Min Qiao, source=Web Response No relevant relationships by Daniel Rudolph, source=Web Response No relevant relationships by Christopher Winterbottom, source=Web Response

Neumomediastino y necrosis cutánea en asociación a dermatomiositis: presentación de un caso clínico y revisión de la literatura

We report a 37 years old male with a dermatomyositis treated with oral cyclophosphamide. He was admitted to the hospital due to a zone of skin necrosis with purulent exudate, located in the second left toe. A complete blood count showed a leukocyte count of 2,600 cells/mm³. A Chest CAT scan showed a pneumomediastinum with emphysema of adjacent soft tissue. Cyclophosphamide was discontinued and leukocyte count improved. The affected toe was amputated and a chest CAT scan showed a partial resolution of the pneumomediastinum. We discuss and review the pathogenesis, clinical presentation and management of pneumomediastinum and cutaneous necrosis in association with dermatomyositis.

Pneumomediastinum caused by isolated oral-facial trauma

Pneumomediastinum from isolated blunt or penetrating oral-facial trauma is a rare occurrence, which can be associated with facial fractures or may be iatrogenic. We present two cases caused by high-pressure-induced facial injuries that had very different management and outcomes. The first patient had asymptomatic pneumomediastinum and an uncomplicated recovery, whereas the second had a complicated clinical course requiring extensive surgical debridement. Neither patient developed mediastinitis as a complication of pneumomediastinum. This case series illustrates isolated facial trauma causing pneumomediastinum and reviews the literature over last 20 years for similar cases. The authors advocate emergency department management of pneumomediastinum from facial trauma.

Two case reports of pneumomediastinum

We present two cases of pneumomediastinum in patients who presented to the accident and emergency department of a large teaching hospital. One case had a history of inhalational drug abuse, which may have contributed to the event, while the other had no obvious precipitating factors. To evaluate the presenting symptoms, physical signs, diagnosis and management of pneumomediastinum with a review of the literature. We describe two cases of pneumomediastinum with a literature review. Pneumomediastinum is an uncommon entity, first described almost 400 years ago. It presents with relatively non-specific symptoms and signs and will require radiological investigations to clarify the diagnosis. Treatment is conservative but will require close observation for the development of complications and occult visceral perforation. Complete resolution can be expected.