Mediastinal emphysema

Classification according to ICD-10
J98.2	Interstitial emphysema Mediastinal emphysema
ICD-10 online (WHO version 2019)

The computed tomography of the chest shows air in the subcutaneous tissue, in the mediastinum and in the back muscles.

The mediastinal emphysema or pneumomediastinum is an accumulation of air in the middle space ( mediastinum ), which is always a sign of disease or injury.

causes

In principle, the air can pass into the mediastinum through perforation from all air-containing organs, i.e. above all the bronchial system or the gastrointestinal tract . A spontaneous pneumomediastinum can be distinguished from a non-spontaneous pneumomediastinum .

Spontaneous pneumomediastinum

The spontaneous pneumomediastinum arises without previous trauma . By definition, there is no underlying lung disease.

The spontaneous pneumomediastinum is usually the result of an intrathoracic pressure increase. As a result, a rupture of the alveoli is likely to result in air transfer along the bronchial system into the mediastinum.

In the majority of cases - around 70% - pressure-increasing factors such as vomiting or violent coughing, physical exertion or bronchial asthma can be determined. In bronchial asthma, the inflammatory reaction probably leads to a rupture of peripheral alveoli. Other causes of spontaneous pneumomediastinum can be the Valsalva maneuver (e.g. during weightlifting or childbirth), narrowing of the airways in bronchitis , inhalation of drugs (e.g. crack or marijuana ), scuba diving or invasive ventilation be.

Non-spontaneous pneumomediastinum

Mediastinal emphysema and right-sided pneumothorax after rib fracture.

The causes of non-spontaneous pneumomediastinum are varied. Frequent and potentially life-threatening causes are the passage of air after perforation of a hollow organ (e.g. the esophagus or the bronchial system ) as a result of a chest trauma, barotrauma or a tumor. Other causes can be swallowing or inhaling foreign bodies (foreign body ingestion or foreign body aspiration).

Iatrogenic, i.e. complications during medical procedures such as bronchoscopy or endoscopy, can lead to a rupture of the windpipe or bronchi, the esophagus, the mediastinum itself or the peritoneum, or inflammation of the mediastinum (mediastinitis). Perforation of the large intestine (e.g. colon cancer or sigmoid diverticulitis) or perforation of a duodenal ulcer can lead to a pneumomediastinum through the entry of air into the retroperitoneum.

Clinical manifestations

In many cases, mediastinal emphysema occurs as part of a pneumothorax or skin emphysema , but does not cause any symptoms of its own. A crackle can often be felt when palpating the jugulum .

With pronounced mediastinal emphysema, the affected patients complain of sharp, pericardial pain . Furthermore, an upper congestion of the influence can be observed with pronounced emphysema .

Investigation methods

The basis for making a diagnosis are the medical history and physical examination .

The diagnosis of pneumomediastinum is made by means of imaging, either by means of conventional x-rays (chest x-ray) or by means of computed tomography of the chest. Computed tomography is more sensitive than conventional X-rays. In addition to detecting even the smallest accumulations of air in the mediastinum, computed tomography also provides information on the possible causes (etiology).

In addition, the blood should be examined and the inflammation parameters ( leukocytes , ESR and CRP ) taken.

In the differential diagnosis of pronounced emphysema, other causes of chest pain should be considered. These include B. a pericarditis , an acute coronary syndrome or a pulmonary embolism .

Furthermore, mediastinitis due to gas-producing bacteria should be excluded.

therapy

Treatment of the underlying disease is fundamental. This includes B. the suturing of a rupture of the esophagus or the trachea and adequate ventilation management. Treatment is usually not required if patients are symptom-free.

If the pain is pronounced, an incision should be made cranial to the sternum and a cannula should be pushed into the mediastinum through which the air can escape.

rapid transport to a hospital
Emergency relief of large mediastinal emphysema through collar mediastinotomy
causal therapy of the cause (pleural puncture and drainage insert for pneumothorax, thoracotomy for injuries to the mediastinal organs)

forecast

The cause determines the prognosis. Patients who have ruptured the esophagus or trachea often develop bacterial mediastinitis.

literature

Liechti ME, Achermann E: [Pneumomediastinum] . In: Dtsch. Med. Wochenschr. . 127, No. 43, October 2002, pp. 2273-6. doi : 10.1055 / s-2002-35014 . PMID 12397542 .
Takada K, Matsumoto S, Hiramatsu T, et al. : Spontaneous pneumomediastinum: an algorithm for diagnosis and management . In: Ther Adv Respir Dis . 3, No. 6, December 2009, pp. 301-7. doi : 10.1177 / 1753465809350888 . PMID 19934282 .
Caceres M, Ali SZ, Braud R, Weiman D, Garrett HE: Spontaneous pneumomediastinum: a comparative study and review of the literature . In: Ann. Thorac. Surg. . 86, No. 3, September 2008, pp. 962-6. doi : 10.1016 / j.athoracsur.2008.04.067 . PMID 18721592 .
Zylak CM, Standen JR, Barnes GR, Zylak CJ: Pneumomediastinum revisited . In: Radiographics . 20, No. 4, 2000, pp. 1043-57. PMID 10903694 .
Bejvan SM, Godwin JD: Pneumomediastinum: old signs and new signs . In: AJR Am J Roentgenol . 166, No. 5, May 1996, pp. 1041-8. PMID 8615238 .
Bullaro FM, Bartoletti SC: Spontaneous pneumomediastinum in children: a literature review . In: Pediatr Emerg Care . 23, No. 1, January 2007, pp. 28-30. doi : 10.1097 / 01.pec.0000248686.88809.fd . PMID 17228218 .

Individual evidence

^ Classen, Diehl, Kochsiek: Internal medicine . 4th edition. Urban & Schwarzenberg, 1998, pp. 1477-1478, ISBN 3-541-11674-9
↑ ^a ^b Olgun H, Türkyilmaz A, Aydin Y, Ceviz N: Spontaneous pneumomediastinum in a child as a rare cause of chest pain . In: Turk Kardiyol Dern Ars . 37, No. 1, January 2009, pp. 51-2. PMID 19225255 .
↑ ^a ^b Abolnik I, Lossos IS, Breuer R: Spontaneous pneumomediastinum. A report of 25 cases . In: Chest . 100, No. 1, July 1991, pp. 93-5. PMID 1824034 .
^ ^A ^b Liechti ME, Achermann E: [Pneumomediastinum] . In: Dtsch. Med. Wochenschr. . 127, No. 43, October 2002, pp. 2273-6. doi : 10.1055 / s-2002-35014 . PMID 12397542 .
↑ Chouliaras K, Bench E, Talving P, Strumwasser A, Benjamin E, Lam L, Inaba K, Demetriades D: Pneumomediastinum following blunt trauma: Worth an exhaustive workup? . In: J Trauma Acute Care Surg . 79, No. 2, 2015, pp. 188-93. doi : 10.1097 / TA.0000000000000714 . PMID 26218684 .

[Classen-1] Classen, Diehl, Kochsiek: Internal medicine . 4th edition. Urban & Schwarzenberg, 1998, pp. 1477-1478, ISBN 3-541-11674-9

[Olgun-2] Olgun H, Türkyilmaz A, Aydin Y, Ceviz N: Spontaneous pneumomediastinum in a child as a rare cause of chest pain . In: Turk Kardiyol Dern Ars . 37, No. 1, January 2009, pp. 51-2. PMID 19225255 .

[Abolnik_I,_Lossos_IS,_Breuer_R_1991_93–5-3] Abolnik I, Lossos IS, Breuer R: Spontaneous pneumomediastinum. A report of 25 cases . In: Chest . 100, No. 1, July 1991, pp. 93-5. PMID 1824034 .

[Liechti-4] A ^b Liechti ME, Achermann E: [Pneumomediastinum] . In: Dtsch. Med. Wochenschr. . 127, No. 43, October 2002, pp. 2273-6. doi : 10.1055 / s-2002-35014 . PMID 12397542 .

[5] Chouliaras K, Bench E, Talving P, Strumwasser A, Benjamin E, Lam L, Inaba K, Demetriades D: Pneumomediastinum following blunt trauma: Worth an exhaustive workup? . In: J Trauma Acute Care Surg . 79, No. 2, 2015, pp. 188-93. doi : 10.1097 / TA.0000000000000714 . PMID 26218684 .