The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pneumomediastinum and is brought to you by Jacob Leedekerken, MD and Chelsea Wilson, MD.
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.
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
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
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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
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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.
22.
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.
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!