Pneumomediastinum

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

Causes

Basically, the air can pass through perforations from all air-containing organs, that is, above all, transgressed the bronchial system or the gastrointestinal tract into the mediastinum. It can be a spontaneous pneumomediastinum be distinguished from a non- spontaneous pneumomediastinum.

Spontaneous pneumomediastinum

The spontaneous pneumomediastinum occurs without a preceding trauma. An underlying lung disease is not by definition.

Spontaneous pneumomediastinum is usually the result of an increase in intrathoracic pressure. It probably comes as a result of a rupture of the alveoli (alveoli ) to an air transfer along the bronchial system into the mediastinum.

In the majority of cases - in around 70 % - can elicit bronchial pressure-raising factors such as vomiting or violent coughing, physical exertion or asthma. Probably the inflammatory response in asthma leads to a rupture of peripheral alveoli. Other causes of spontaneous pneumomediastinum can the Valsalva maneuver ( eg in the context of weight lifting or childbirth ), a narrowing of the airways in bronchitis, inhalation of drugs (such as crack or marijuana), scuba diving or invasive ventilation be.

Non - spontaneous pneumomediastinum

The causes of spontaneous pneumothorax are not diverse. Frequent and potentially life-threatening causes are the passage of air to the perforation of a hollow organ (eg, esophageal or bronchial ) as a result of chest trauma or tumor disease. Additional causes may include the ingestion or inhalation of a foreign body ( foreign body ingestion or aspiration of foreign bodies ).

Also, iatrogenic, that is, due to complications in the context of medical measures such as bronchoscopy or endoscopy may lead to a rupture of the trachea or bronchi, esophagus, mediastinum itself or of the peritoneum. his or inflammation of the mediastinum ( mediastinitis ). By perforation of the colon (e.g. colon cancer or diverticulitis Sigma ) or by perforation of a duodenal ulcer may occur on entry of air into the retroperitoneum to a pneumomediastinum.

Clinical manifestations

In many cases the mediastinal under a pneumothorax or subcutaneous emphysema occurs, but causes no own symptoms thereby. On palpation of the jugular notch is often a crackle buttons.

In severe mediastinal emphysema affected patients complain of sharp, pericardial pain. Furthermore, in a pronounced emphysema, an upper caval be observed.

Methods of investigation

Basis for diagnosis are the history and the physical examination.

The diagnosis of pneumomediastinum is provided by means of imaging, either by conventional radiograph ( X -ray ) or by computed tomography of the thorax. Computed tomography is more sensitive than the conventional X-ray. In addition to the detection of even the smallest accumulation of air in the mediastinum, computed tomography will also provide guidance on the possible causes (etiology ).

In addition, the blood studied, and the parameters of inflammation (leukocytes, ESR and CRP) should be removed.

The differential diagnosis should be considered in a pronounced emphysema to other causes of chest pain. These include, for example, pericarditis, acute coronary syndrome or pulmonary embolism.

Furthermore mediastinitis should be ruled out by gas-forming bacteria.

Therapy

Fundamentally, the treatment of the underlying disease. This includes, for example, the seam of a rupture of the esophagus or the trachea, as well as adequate ventilation management. If the patients free of symptoms, no treatment is necessary as a rule.

In severe pain, an incision should be cranial to the sternum performed and a cannula is advanced into the mediastinum, through which the air can escape.

• Speedy transport to a hospital
• Moderate emergency relief large mediastinal emphysema by kollare mediastinotomy
• Causal treatment of the cause ( thoracentesis and drainage deposit with pneumothorax, thoracotomy with violations of mediastinal )

Forecast

The cause determines the prognosis. Patients with a rupture of the esophagus or the trachea often develop bacterial mediastinitis.