PNEUMOMEDIASTINUM

Pneumomediastinum: A Case Study

Katherine V. Konnert
ALH1015C001 Human Disease
December 4, 2015

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Date: 03/11/2015
Name: Helen Parle
DOB: 10/27/1985
Race: Caucasian
Occupation: Meteorologist
Chief Complaint: The middle of my chest really hurts when I breathe, and I dont know why.
Subjective: 30 year old female patient presents with acute, retrosternal pain that worsens with
inspiration.
Differential Diagnosis
Pleuritis

Medial pneumothorax

Myocardial Infarction

Pneumonia

Pneumomediastinum

Clinical Presentation
Sharp chest pain upon inspiration and expiration that may get
worse with movement, fever, chills, anorexia, pain in shoulders
and back, headache, arthralgia, myalgia, dyspnea, dry cough,
plural effusion, empyema, inflammation of lungs, and/or fluid
buildup present on imaging reports, bacterial or viral infection.
Pleuritic chest pain, dyspnea, subcutaneous emphysema,
pneumomediastinum, underlying lung disease, imaging may
show collapsed lung, radiolucent peripheral space, visible
visceral pleural edge as a white line.
Chest pain or discomfort, upper body discomfort, dyspnea,
diaphoresis, nausea, light-headedness, fatigue, ECG may show
signs of irregular electrical activity, high levels of proteins in the
blood.
Chest pain that worsens with deep breathing or coughing, fever,
chills, dyspnea, malaise, headache, fatigue, anorexia,
leukonychia, confusion, bacterial or viral infection, pleural
fluid, increased WBC count.
Retrosternal chest pain increasing upon inspiration and
swallowing, pain spreading to back or arms, low grade fever,
dyspnea, abnormal oxygen saturation, associated
pneumothorax, collapsed lung, imaging reports show air in the
mediastinum, possible hole in trachea or esophagus, Patient may
be asymptomatic.

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HPI: Patient presents with acute, retrosternal chest pain, which worsens with inspiration.
Experiencing mild dyspnea due to painful breathing. Onset of pain was 2 hours ago. Presence
of low-grade fever. Slightly low oxygen saturation. BP and HR normal. No wheezing. No
history of respiratory or cardiac issues. Denies recent pregnancy, injury, illness or scuba diving.
Diagnostic Tests:

Electrocardiography (ECG)
Laboratory studies: ABG, cardiac enzymes, toxicology
Imaging studies: chest CT scan

Results:

ECG normal
ABG normal, cardiac enzymes normal, toxicology negative
CT abnormal with free air observed in the mediastinum

Table 1. Differential Diagnosis, Pertinent Positives, and Negatives

Differential
Diagnosis
Pleuritis

Medial

Pertinent Positives
(supports dx)
Sharp chest pain upon
inspiration and expiration
that may get worse with
movement, fever, pain in
shoulders and back, dyspnea
Chest pain, dyspnea

pneumothorax

Myocardial
Infarction

Chest pain, dyspnea

Pneumonia

Chest pain that worsens with

deep breathing or coughing,
fever, dyspnea

Pertinent Negatives
(not support dx)
Chills, anorexia, headache, arthralgia, myalgia,
dyspnea, dry cough, plural effusion, empyema,
inflammation of lungs, and/or fluid buildup
present on imaging reports, bacterial or viral
infection.
Subcutaneous emphysema,
pneumomediastinum, underlying lung disease,
imaging may show collapsed lung, radiolucent
peripheral space, visible visceral pleural edge
as a white line.
Upper body discomfort, diaphoresis, nausea,
light-headedness, fatigue, ECG may show
signs of irregular electrical activity, high levels
of proteins in the blood.
Chills, malaise, headache, fatigue, anorexia,
leukonychia, confusion, bacterial or viral
infection, pleural fluid, increased WBC count

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Pneumomediastinum

Retrosternal chest pain

spreading to back or arms,
pain increasing upon
inspiration, low grade fever,
dyspnea, abnormal oxygen
saturation, imaging reports
show air in the mediastinum

4
Pain worsening with swallowing, associated
pneumothorax, collapsed lung, possible hole in
trachea or esophagus. Patient may be
asymptomatic.

Treatment Options:
Treatment for pneumomediastinum depends upon the clinical status of the patient and the
severity of the condition. In this case (like most cases), treatment beyond rest, analgesics,
oxygen, and imaging studies is not required, the patient should be advised to avoid risk factors
for pneumomediastinum for 6 months. The risk factors include avoiding strenuous activity,
scuba diving, playing wind instruments, mechanical ventilation, GERD, recurrent vomiting, and
asthma (Carolan, 2015). Follow-up imaging should be performed to confirm that the condition
has resolved. Should the clinical status of the patient worsen, the following treatments options
may be explored:

Mechanical Ventilation (MV) utilizing the lowest pressure or tidal volumes

necessary A machine (ventilator) with an endotracheal tube is used to aid
respiration.
Pros: respiratory support to reduce symptoms of respiratory distress.
Cons: does not eliminate the air in the mediastinum, may cause another
air leak, various complications (fistula, oxygen toxicity, hypotension,
sinusitis, tracheal stenosis, vocal cord injury, pneumonia, lung damage,
pneumothorax), nutritional support may become necessary, various
complications of immobility (venous thromboembolic disease, skin
breakdown, atelectasis), may require sedation.
Intercostal Drain Insertion a tube is guided inserted through the chest wall and
into the pleural space to drain the air.
Pros: small drain, can be guided by ultrasound, removes the air which will
reduce dyspnea and pain during respiration.
Cons: pain, complications (bleeding infection, damage to surrounding
structures).
Needle Aspiration the air in the mediastinum is aspirated using a needle.

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Pros: accurate, minor procedure, reduces dyspnea and pain during

respiration.
Cons: complications (bleeding, bruising, infection).
Analgesics Nonopioid or opioid, depending on the severity of the pain.
Pros: reduces pain.
Cons: pain, possible allergic reactions and/or side effects.
Oxygen Therapy obtain oxygen through nasal cannula or mask.
Pros: decrease dyspnea and increase oxygen saturation.
Cons: uncomfortable, fire hazard.
Rest avoid strenuous activity.

Pros: decreased pain, no side effects.

Cons: limits activity.

Prognosis:
The outlook for this patient is positive, because in most cases of spontaneous
pneumomediastinum, the air in the mediastinal structures dissipates, resolving the condition
within several days of treatment. More severe cases, that may involve a collapsed lung or hole in
the in the trachea or esophagus, require aggressive treatment, and most patients respond well.
The risk of recurrence is low if patients avoid risk factors and receive follow-up care (U.S.
National Library of Medicine, 2015).
Pathophysiology:
Although the patients symptoms point to several differential diagnoses,
Pneumomediastinum is the conclusive diagnosis because of the pertinent positive symptoms, low
oxygen saturation, and the abnormal diagnostic CT scan result, which revealed interstitial air in
the mediastinum. Pneumomediastinum (also called, mediastinal emphysema) is the presence of
interstitial air outside of the lungs, in the mediastinum, otherwise known as the chest cavity. The
condition is rare and results from the leakage of air, from the lungs, into the mediastinum. This
leakage can happen spontaneously, as in the case of this patient, or be caused by increased
pressure in the lungs or airways from coughing, bearing down during childbirth or a bowel

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movement, sneezing, or vomiting. An infection in the neck or chest, an esophageal or tracheal

tear, the inhalation of recreational drugs, rapid rises in altitude, scuba diving, or use of
mechanical ventilation may also cause air to seep into the mediastinum. Possible signs and
symptoms are included in Table 2, detailing the comparison of the normal physiology to the
diseased state of pneumomediastinum.
There is the potential for the condition to become serious and warrant aggressive
treatment. For example, the buildup of air around the lungs may escape into the pleural space
and cause a lung to collapse. However, it is more likely that a patient may be asymptomatic, or
only experience minor symptoms that require diagnostic and follow-up CT scans, analgesics,
rest, and initial oxygen therapy (Carolan, 2015; Escobar, et al., 2007; Gorrochategui & Smith,
2015).
Table 2. Normal Physiology and the Diseased State of Pneumomediastinum
Normal Physiology
No interstitial air in mediastinum.
The area is free of air on CT scan.
Respiration not painful.
Oxygen saturation 95-100%, with
normal respiration.
Normal temperature 98.6 F.
No interstitial air in pleural space.
The area is free of air CT scan.
Imaging reveals healthy and
functioning lungs, trachea, and
esophagus.

Diseased State of Pneumomediastinum

Interstitial air in mediastinum.
Abnormal CT with air visible in mediastinum.
Retrosternal chest pain, especially with inspiration.
Oxygen saturation below 95% and accompanied by
dyspnea.
Low grade fever 99-100.4 F.
Air present in pleural space (pneumothorax).
Abnormal CT with air visible in pleural space.
Imaging may reveal collapsed lung, and/or hole in
esophagus or trachea.

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References

American Academy of Otolaryngology- Head and Neck Surgery. (2015). Fine Needle Aspiration.
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http://www.entnet.org/?q=node/1471
Carolan, P. L. (2015). Pneumomediastinum. Retrieved from Medscape:
http://emedicine.medscape.com/article/1003409-overview
Escobar, I., Macia, I., Morera, R., Moya, J., Perna, V., Ramos, R., . . . Saumench, J. (2007).
Spontaneous pneumomediastinum: 41 cases. European Journal of Cardio-Thoracic
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Gorrochategui, M., & Smith, D. (2015). Pneumomediastinum. Retrieved from Radiopaedia.org:
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U.S. National Library of Medicine. (2015). Pneumomediastinum. Retrieved from MedlinePlus:
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