pneumomediastinum “mediastinal emphysema”...pathophysiology pneumothorax (51%) macklin effect...
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PNEUMOMEDIASTINUM
“Mediastinal Emphysema”
Alan H. Tyroch, MD, FACS, FCCM
Professor & Founding Chair of Surgery
Trauma Medical Director
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PNEUMOMEDIASTINUM
Presence of air within the mediastinum
Laennec (1819): Traumatic
Hamman (1939): Spontaneous
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PNEUMOMEDIASTINUM
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CLASSIFICATION
SPONTANEOUS
Asthma
COPD
Interstitial lung disease
Child birth
Malignancy
Physical activity/sports
Cough/emesis
Recreational drug use
SECONDARY
Blunt trauma
Penetrating trauma
Iatrogenic
Hollow viscus
perforation
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PATHOPHYSIOLOGY
Pneumothorax (51%)
Macklin effect (39%)
Hypopharyngeal or laryngeal injury
Gastrointestinal tract injury
Mediastinal organ injury:
Tracheobronchial tree (<10%)
Esophagus (1-2%)
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MACKLIN EFFECT (1939)
Alveolar rupture due to increase intrathoracic pressure
Air dissects through the peribronchovascular sheaths
towards the pulmonary hilum
Air extends into the mediastinum
Pulmonary Pressure > Mediastinal Pressure
AND
Facilitated by pumping action of breathing
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MACKLIN EFFECT
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SYMPTOMS
TRIAD
Hamman’s Sign
Thoracic Pain
Dyspnea
OTHER
Cough
Fever
Dysphagia
Dysphonia
Odynophagia
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The Evaluation of Pneumomediastinum
in Blunt Trauma Patients
Dissanaike S, et al.
J Trauma, 2008
Mechanism:
MVC: 58%
Fall: 21%
MCC/ATV: 13%
Crepitus: 35%
Chest pain: 24%
Dyspnea: 15%
Hoarseness: 8%
Associated injuries:
Pneumothorax: 68%
Hemothorax: 16%
Sternal fracture: 6%
Airway injury: 6%
Esophageal injury: 1.5%
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The Evaluation of Pneumomediastinum
in Blunt Trauma Patients
Dissanaike S, et al.
J Trauma, 2008
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Pneumomediastinum in Blunt Trauma: A Review
Bergen V, et al.
Trauma, 2011
Imaging studies:
CXR: 13% sensitivity
CT scan: 100% sensitivity
CT scan for detecting mediastinal organ injuries:
100% sensitivity
85% specificity
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Pneumomediastinum in Blunt Trauma: A Review
Bergen V, et al.
Trauma, 2011
Uncommon finding after blunt trauma
Usually benign
~6% have aerodigestive injury
Hoarseness, dyspnea, or persistent lung collapse/air leak
increases suspicion for injury to the larynx, trachea, bronchi or
esophagus
CT scan is the 1st line study
Bronchoscopy & Esophagram selectively
Clinical &/or CT findings
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Pneumomediastinum: Etiology &
A Guide to Diagnosis & Treatment
Banki F, et al.
Am J Surg, 2013
To identify predictive
factors of mediastinal
organ injury in patients
with
pneumomediastinum
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Mediastinal Injury:
Trauma (279)
266
10 3 0
50
100
150
200
250
300
No aerodigestive injury Airway injury Esophageal injury
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Mediastinal Injury:
Non-Trauma (64)
36
17
9
2
0
5
10
15
20
25
30
35
40
Spont PTX Esophageal injury Pneumothorax Airway injury
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Airway Injury
Trauma (13)
Airway (10)
Stab wound: 3
GSW: 2
MVC-2
Traumatic intubation: 2
Crush injury to neck: 1
Esophageal (3)
SW: 1
GSW: 1
MVC: 1
Non-trauma (19)
Esophageal (17)
Boerhaave’s syndrome:
11
EGD: 4
Cervical fusion: 2
Airway (2)
Intubation: 2
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Pneumomediastinum: Etiology &
A Guide to Diagnosis & Treatment Banki F, et al
Am J Surg, 2013
Esophageal injury:
Instrumentation (OR: 46)
Pleural effusion (OR: 11)
Vomiting (OR: 9)
Airway injury:
Instrumentation (OR: 9)
Pneumothorax:
A strong negative indicator (OR: 0.06) of esophageal injury
Not associated with airway injury
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Pneumomediastinum: Etiology &
A Guide to Diagnosis & Treatment Banki F, et al
Am J Surg, 2013
Most do not have aerodigestive injuries
Pneumomediastinum is of no clinical significance
Patients should be treated on their overall clinical findings,
associated injuries & imaging
Mediastinal organ injury should be detected based on H&P
with a focus on: Recent instrumentation of esophagus or airway
History of vomiting
Presence of a pleural effusion
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Other Studies
Blunt Trauma (n) Pneumomediastinum Aerodigestive Injury
9,946 2.6% (258) 1.6% (4)
2,052 2.7% (55) 0% (0)
1,364 5.2% (71) 10.3% (8)
897 6.5% (58) 0% (0)
3,327 2.2% (72) NA
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UMC El Paso (2000 - 2015)
102 patients
0.3% all admissions
89% blunt
mechanism
75% male
Mortality: 3.9%
Mean age: 36.5
Mean ISS: 21.6
Mean LOS: 9.6 days
Mean vent. days: 3.5
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UMC El Paso (2000 - 2015)
n = 102
MVC 41%
Fall 16%
MCC 13%
Aped 12%
GSW/SW 10%
Other 8%
53%
4% 3% 0 0 0%
10%
20%
30%
40%
50%
60%
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Computed Tomographic Findings & Mortality
in Patients with Pneumomediastinum
from Blunt Trauma Lee W, el al.
JAMA Surg, 2015
To characterize CT findings
associated with mortality in
blunt trauma patients with
pneumomediastinum
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Computed Tomographic Findings & Mortality in Patients
with Pneumomediastinum from Blunt Trauma Lee W, el al.
JAMA Surg, 2015
Pneumomediasinum size was not associated with mortality
(P=.22)
Posterior mediastinum
Mortality: 25% (7 of 28 pts; P = .007)
All mediastinal compartments
Mortality: 40% (4 of 10 patients; P = .01)
Hemothorax
Mortality: 22% (8 of 36 pts; P = .01)
CT Scan: A triage tool to alert the trauma surgeon to a potentially lethal injury
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MANAGEMENT
Conservative
Analgesia
Rest
Avoid maneuvers that increase pulmonary pressure
Valsalva
Cough or emesis
High PEEP or high tidal volume
High concentration of oxygen
Identify & treat
Uncommon mediastinal organ injury
Rare tension pneumomediastinum or tension
pneumopericardium
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SUMMARY
Rare
Benign
Aerodigestive injuries uncommon
CT scan as screening tool
History & Physical Exam
Selective use of bronchoscopy or esophagram