1. Pneumomediastinum
Chelsea Wilson, MD & Jacob Leedekerken, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Charlotte, North Carolina
Michael Gibbs, MD, Faculty Editor
The Chest X-Ray Mastery Project

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: pneumomediastinum.

4. Visit Our Website
www.EMGuidewire.com
For a complete archive of Chest X-Ray presentations and much more!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. Definition
Extraluminal gas within mediastinum often originating from lungs,
trachea, central bronchi, esophagus, and/or peritoneal cavity.
Symptoms
 Chest Pain (55%)
 Dyspnea (40%)
 Cough (32%)
 Neck Pain (17%)
 Odynophagia (14%)
 Dysphagia (10%)
Signs
 SQ Emphysema (30-90%)
 Hamman’s Crunch (12-50%)
 Dyspnea (30-60%)
Pneumomediastinum - Background

8. Pneumomediastinum - Imaging
Nguyen, J and Lee, M.
“A Case of the Incidentally Discovered Pneumomediastinum.”
Imaging Choice
 Lateral soft tissue neck – most sensitive of the diagnostic
x-rays
 CT – helps define the full extend of disease
Imaging Signs
 Free air along mediastinum
 Subcutaneous air in neck/shoulders
 Continuous diaphragm sign (air below heart)
 Naclerio V Sign (well demarcated “V” along left heart border &
diaphragm)
 Air along great vessels/heart border

9. Continuous Diaphragm Sign
Naclerio V
Sign

10. 2° Iatrogenic 2° Medical & Traumatic Spontaneous
 Endoscopic procedures
 Intubation
 Pleural instrumentation
 Central vascular procedure
 Chest/abdominal surgery
 Blunt chest injury
 Penetrating chest injury
 Asthma/COPD
 Bronchiectasis
 Interstitial lung disease
 Thoracic malignancy
 Tobacco use
 Recreational drugs
 Breath holding
 Weightlifting
Vasileios K. Journal of Thoracic Disease 2015; 7:S44-S49.
Management Essentials
 Manage the underlying cause
 Pain management & cough suppression as indicated
 Oxygen may increase gas absorption in severe cases
 Brief period of observation vs. close outpatient follow-up
 If concern for esophageal source -> esophagram, broad spectrum
antibiotics, admission, and surgical consult
Pneumomediastinum – Causes & Management

15. Conclusions
Spontaneous pneumomediastinum:
• A benign condition seen primarily in younger adults that is associated
with an uneventful recovery and unlikely recurrence
• In most cases the presentation involves chest pain, dyspnea, cough,
and/or subcutaneous emphysema
• The diagnosis requires a high index of suspicion because 30% of
patients present without any precipitating factors and 30% of patients
will have a normal initial chest X-ray

16. Conclusions
Secondary pneumomediastinum, that had a 39% mortality in this
study, is associated with:
• An older age at presentation
• A higher prevalence of associated pneumothorax
• A higher requirement for tube thoracostomy drainage
• The presence of a pleural effusion
• Longer hospital stays

21. Patient #1
52-year-old admitted with dyspnea, fever, cough. He was initially started on non-invasive
ventilation but worsened and required endotracheal intubation. Post-intubation reveal
consolidation and pneumomediastinum [Fig 1a]. He improved with supportive care.
Patient #2
68-year-old admitted with dyspnea requiring increasing CPAP support. Following intubation
imaging reveals pneumomediastinum with widespread extension. He did develop a
pneumothorax requiring drainage. He subsequently improved with complete resolution.
Patient #3
66-year-old requiring admission and early intubation. Chest X-ray revealed extensive
pneumomediastinum. Serial CXR confirmed gradual resolution.

23. Discussion
• In the patient with COVID-19, pneumomediastinum appears to be the
consequence of the high PEEP required to maintain oxygenation.
• In this case series all patient had gradual resolution of their
pneumomediastinum.
• While the patient is intubated, serial chest X-rays are recommended
to monitor for the possibility of iatrogenic pneumothorax.

24. Carolinas Medical Center Case Studies

25. Case #1
Gunshot
Wound To
The Neck.
Injury To The Trachea & Esophagus.

26. Injury To The Trachea & Esophagus.
Case #1
Gunshot
Wound To
The Neck.

27. Case #1
Gunshot
Wound To
The Neck.

28. Pneumomediastinum
Case #1
Gunshot
Wound To
The Neck.

29. Case #1
Gunshot
Wound To
The Neck.

30. Pneumomediastinum
Pneumomediastinum
Pneumomediastinum
Case #1
Gunshot
Wound To
The Neck.

31. Case #2: 13-Year-Old With Throat And Chest Pain.

32. Case #2: 13-Year-Old With Throat And Chest Pain.
Pneumomediastinum & Pneumopericardium

33. Pneumomediastinum & Pneumopericardium
Case #2: 13-Year-Old With Throat And Chest Pain.

34. Pneumomediastinum & Pneumopericardium
Case #2: 13-Year-Old With Throat And Chest Pain.

35. Case #3:
Young Male With
Intractable
Vomiting.

36. Pneumomediastinum & Pneumopericardium
Case #3:
Young Male With
Intractable
Vomiting.

37. Case #3: Young Male With Intractable Vomiting.

38. Pneumomediastinum & Pneumopericardium
Case #3: Young Male With Intractable Vomiting.

39. Case #4: 25-Year Old With Repeated Episodes Of
Vomiting.

40. Pneumomediastinum
Case #4: 25-Year Old With Repeated Episodes Of
Vomiting.

41. Case #4: 25-Year Old With Repeated Episodes Of
Vomiting.
Pneumomediastinum

42. If you have an interesting case of pneumomediastinum, we to send a set of
digital PDF images and a brief descriptive clinical history to:
michael.gibbs@atriumhealth.org
Your de-identified case(s) will be posted on our education website and you
and your institution will be recognized!