1. PneumomediastinuPneumomediastinu
mm
Tyler BagleyTyler Bagley
October 17, 2006October 17, 2006

2. ObjectivesObjectives
 1. Recognize the causes of1. Recognize the causes of
pneumomediastinumpneumomediastinum
 2. Recognize the presentation2. Recognize the presentation
 3. Identify common radiological signs3. Identify common radiological signs
 4. Discuss when to order additional tests4. Discuss when to order additional tests
 5. Treatment5. Treatment

3. Pulmonary Causes:Pulmonary Causes:
 Rupture of the alveolus with air dissectionRupture of the alveolus with air dissection
along the peribronchial vascular sheaths intoalong the peribronchial vascular sheaths into
the hilum and mediastinumthe hilum and mediastinum
 Ruptured bleb with peripheral extensionRuptured bleb with peripheral extension
 Sudden rise in intrapulmonary pressureSudden rise in intrapulmonary pressure
 Asthma, vomiting, forceful coughing, crying,Asthma, vomiting, forceful coughing, crying,
shouting, Valsalva maneuver, artificial ventilation,shouting, Valsalva maneuver, artificial ventilation,
closed chest trauma, sudden drop in atmosphericclosed chest trauma, sudden drop in atmospheric
pressure, foreign body aspirationpressure, foreign body aspiration

4. TraumaTrauma
 Rupture of trachea or mainstemRupture of trachea or mainstem
bronchus, usually via accidental traumabronchus, usually via accidental trauma
 Trauma to the neckTrauma to the neck
 Boerhaave’s SyndromeBoerhaave’s Syndrome
 BarotraumaBarotrauma

5. MediastinumMediastinum
ConnectionsConnections
 The mediastinum communicates with theThe mediastinum communicates with the
submandibular space, retropharyngealsubmandibular space, retropharyngeal
space and vascular sheaths within thespace and vascular sheaths within the
neckneck
 Also can communicate with theAlso can communicate with the
retroperitoneum via sternocostalretroperitoneum via sternocostal
attachments to the diaphragm, as well asattachments to the diaphragm, as well as
the periaortic and periesophageal fascialthe periaortic and periesophageal fascial
planesplanes

6. PresentationPresentation
 Infants-typically noneInfants-typically none
 Adults-Adults-
 May complain of retrosternal chest pain radiatingMay complain of retrosternal chest pain radiating
down both arms that is exacerbated by respirationdown both arms that is exacerbated by respiration
and swallowingand swallowing
 Dyspnea-in association with asthma, tension PM orDyspnea-in association with asthma, tension PM or
pneumothoraxpneumothorax
 Fever-due to cytokine release with an air leakFever-due to cytokine release with an air leak
 Throat or jaw pain, dysphonia, dysphagia, neckThroat or jaw pain, dysphonia, dysphagia, neck
swelling and torticollisswelling and torticollis

7. Physical ExamPhysical Exam
 Subcutaneous AirSubcutaneous Air
 Associated PneumothoraxAssociated Pneumothorax
 Oxygen SaturationsOxygen Saturations
 Hamman’s Sign-Hamman’s Sign-
 ““Crunching” sound heard over the apex ofCrunching” sound heard over the apex of
the heart with the cardiac cyclethe heart with the cardiac cycle

8. Linear density parallelLinear density parallel
to the heart borderto the heart border

9. Extrapleural SignExtrapleural Sign
 Air from theAir from the
mediastinum canmediastinum can
extend laterallyextend laterally
between the parietalbetween the parietal
pleura and thepleura and the
diaphragm todiaphragm to
produce theproduce the
extrapleural signextrapleural sign

10. Double Bronchial SignDouble Bronchial Sign
 Air in theAir in the
mediastinum and leftmediastinum and left
main bronchusmain bronchus
allows visualizationallows visualization
of both sides of theof both sides of the
bronchial wall.bronchial wall.

11. Spinnaker SignSpinnaker Sign
(Thymic Sail Sign)(Thymic Sail Sign)
With sufficient
mediastinal air, the
thymus can
become elevated,
creating the
Thymic Sail Sign,
or Spinnaker Sign.

12. NewbornNewborn
PneumomediastinumPneumomediastinum

13. Air in AnteriorAir in Anterior
MediastinumMediastinum

14. Tubular Artery SignTubular Artery Sign

15. Continuous DiaphragmContinuous Diaphragm
SignSign

16. Ring around the ArteryRing around the Artery
SignSign

17. Chest CTChest CT

18. Diagnostic ProceduresDiagnostic Procedures
 Chest tube in coexisting pneumothoraxChest tube in coexisting pneumothorax
 Bronchoscopy if tracheobronchialBronchoscopy if tracheobronchial
perforation is suspectedperforation is suspected
 Esophagoscopy if an esophagealEsophagoscopy if an esophageal
perforation is suspectedperforation is suspected

19. TreatmentTreatment
 Mechanical ventilation with low pressureMechanical ventilation with low pressure
or tidal volumesor tidal volumes
 Mediastinoscopy to alleviate life-Mediastinoscopy to alleviate life-
threatening pneumomediastinumthreatening pneumomediastinum
 Percutaneous placement of mediastinalPercutaneous placement of mediastinal
drainsdrains

20. The End.