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Practice CMAJ

Cases

Pneumomediastinum and subcutaneous emphysema

Sharmila Udupa MD, Tahir Hameed MD, Tom Kovesi MD

See also practice article by Yazer and colleagues, page 215

A
Competing interests: None nine-year-old girl presented to the tation in lateral neck movement, but no subcuta-
declared for Sharmila emergency department in the fall of neous emphysema on palpation. Neck and chest
Udupa and Tahir Hameed.
Tom Kovesi has received 2009 with a one-week history of radiographs showed subcutaneous air at the ster-
payment for lectures from cough, neck swelling, sore throat and mild diar- noclavicular notch and anterior to the cervical
Nycomed Canada Inc. and rhea, but no fever or vomiting. She had a history vertebra, but no pneumomediastinum or pneu-
Merck Frosst Canada Ltd.,
and payment for educational
of asthma, which was treated with montelukast. mopericardium. Testing of nasal secretions by
presentations from Her physical examination showed subcutaneous polymerase chain reaction was positive for pan-
AstraZeneca Canada Inc. emphysema above the clavicles. A chest radi- demic (H1N1) 2009 virus. He was given oral
This article has been peer ograph showed pneumomediastinum (Figure 1). oseltamivir; he rapidly improved and was dis-
reviewed. She was discharged home but returned several charged within three days.
Correspondence to: hours later with worsening symptoms. A neck A three-year-old boy presented to the emer-
Dr. Tom Kovesi, radiograph showed massive subcutaneous em- gency department in the fall of 2009 with a four-
kovesi@cheo.on.ca physema in the prevertebral space (Figure 2). day history of fever, cough, runny nose and
CMAJ 2011. DOI:10.1503 An echocardiogram showed a very small local- sudden-onset neck swelling. He had vomited
/cmaj.100099 ized pneumopericardium over the left ventricle. once. He had been diagnosed with asthma six
Polymerase chain reaction testing of nasal secre- months earlier, but had been using inhaled corti-
tions was positive for pandemic (H1N1) 2009 costeroids and bronchodilators inconsistently for
virus. She was admitted to the pediatric inten- the past five months. He was tachycardic, with
sive care unit and given 100% oxygen therapy, a maximum heart rate of 160 beats/min, and
inhaled salbutamol and oral oseltamivir. She tachypneic, with a maximum respiratory rate of
was also given antibiotics empirically, because 62 breaths/min. He required supplemental oxy-
of the potential loss of sterility of the preverte- gen to maintain oxygen saturation above 92%.
bral space. Apart from lingering fever, she There was palpable subcutaneous emphysema at
recovered uneventfully and was discharged after the face, neck, chest and upper abdomen. He had
five days. increased respiratory effort and a prolonged
A 14-year-old boy presented to the emer- expiratory phase. His chest radiograph showed
gency department in the fall of 2009 with a five- subcutaneous emphysema and pneumomedi-
day history of fever, cough, sore throat, abdomi- astinum. Testing of his nasal secretions by poly-
nal pain and fatigue. There was no history of merase chain reaction was positive for pandemic
vomiting. He had a history of very mild asthma, (H1N1) 2009 virus. He was given oral osel-
having last used inhaled salbutamol over a year tamivir, 100% oxygen therapy, antibiotics,
earlier. He had mild tachypnea. There was limi- inhaled salbutamol and oral corticosteroids. He
had an uncomplicated course and was dis-
charged after four days.
Key points
• Pneumomediastinum should be considered in children with pandemic Discussion
(H1N1) influenza who have dyspnea or chest pain, particularly if they
have a history of asthma.
Infection with pandemic (H1N1) 2009 virus has
• In a child with pneumomediastinum, serious underlying causes, such as
esophageal perforation or foreign body ingestion, should be excluded.
been associated with severe respiratory compli-
cations in children, including secondary bacterial
• In most children, isolated spontaneous pneumomediastinum can be
managed with careful clinical observation. pneumonia and respiratory failure.1 A recent
report described the association of pandemic

220 CMAJ, February 8, 2011, 183(2) © 2011 Canadian Medical Association or its licensors
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(H1N1) influenza and pneumomediastinum in or 3 per 1000 children presenting with asthma to
two Japanese children.2 Although there is a well- an emergency department.3 We observed three
established link between underlying respiratory instances of spontaneous pneumomediastinum
illnesses, especially asthma, and spontaneous among 110 children admitted during the second
pneumomediastinum,3,4 our experience with the wave of pandemic (H1N1) 2009. In contrast,
three patients we have described supports the five patients were admitted with pneumomedi-
association of pandemic (H1N1) influenza with astinum in each of the two preceding years out
air leak syndrome, including pneumomedi- of a total of 6083 patients in 2007 and 6266
astinum, and subcutaneous and prevertebral patients in 2008 (Nicole Beaulieu, Certified
emphysema in a different pediatric population. Health Information Management Professional,
Decision Support, Children’s Hospital of Eastern
Spontaneous pneumomediastinum Ontario: personal communication, 2009), sug-
Spontaneous pneumomediastinum is related to gesting the incidence is markedly increased in
Valsalva manoeuvres (e.g., coughing, vomiting, children with pandemic (H1N1) influenza.
labour, sneezing, use of inhaled medication), Pneumomediastinum usually results from
severe bronchopulmonary infection (e.g., mea- mechanisms that increase alveolar pressure,
sles, mycoplasma pneumonia), foreign body which leads to alveolar rupture. By direct
ingestion, esophageal rupture and dental surgery, extension, air enters interstitial tissues and
although there can be no identifiable cause. extends easily into mediastinal borders. Air can
Pneumomediastinum can also occur secondary then readily communicate with connective tis-
to chest injury, mechanical ventilation and tho- sues in the cervical, endothoracic, peritoneal
racic surgery.3,4 Because an inciting event may be and even vertebral areas.3,4 In severe pneumo-
identifiable in up to 70%–90% of cases,3 the mediastinum, the trapped air can cause airway
absence of an obvious event in all of our patients obstruction or impingement in venous return
is unusual. via tamponade.4
Previous reviews have recommended exclud- Spontaneous pneumomediastinum may be
ing serious underlying causes such as esophageal missed because of its subtle clinical findings.
perforation due to vomiting or ingesting a for- Signs and symptoms include cough, dyspnea,
eign body (Boerhaave syndrome), as well as subcutaneous emphysema and chest pain.3,4 Sub-
other serious causes of chest pain, including pul- tler symptoms include sore throat, neck pain,
monary embolism and pericarditis.3,4 voice change and odynophagia.3,4
Spontaneous pneumomediastinum is rare in Diagnosis is confirmed with imaging. Radi-
children. Its precise incidence is unknown, but ographic findings include air streaks outlining
estimates range from 1 in 800 to 1 in 42 000 mediastinal structures, especially around cardiac
patients presenting to an emergency department, landmarks. Two views are helpful; findings may

Figure 1: Chest radiograph of a nine-year-old girl Figure 2: Lateral radiograph of the neck showing
showing subcutaneous emphysema (black arrow) prevertebral air (black arrow) and massive subcuta-
and pneumomediastinum (white arrow). neous emphysema (white arrow).

CMAJ, February 8, 2011, 183(2) 221

Practice

be present only on a lateral radiograph.3 Com- air leak complicating pandemic (H1N1)
puted tomography (CT) has greater sensitivity influenza in adults. All three of our patients had
for the detection of pneumomediastinum and is a history of mild asthma. A recent retrospective
considered the gold standard for its diagnosis.4 If study conducted at a pediatric hospital in Canada
a serious underlying cause is suspected, such as suggested that even mild asthma is a risk factor
perforation of the esophagus, or if signs such as for severe pandemic (H1N1) influenza and ad-
fever, hypotension and leukocytosis are present, mission to hospital.5 Asthma may augment the
then CT or contrast-enhanced swallow radiogra- risk of airway epithelial injury or increase the
phy (or both) is indicated.3 risk of alveolar rupture due to pre-existing lung
The rate of complications of pneumomedi- hyperinflation. Pandemic (H1N1) influenza
astinum, such as pneumopericardium, pneu- appears to be associated with pneumomedi-
mothorax and pseudotamponade, is unknown, astinum and subcutaneous and prevertebral
but complications are thought to be rare. Pneu- emphysema in children. These conditions should
momediastinum on its own is generally not be excluded in children with pandemic (H1N1)
harmful and has a low rate of recurrence.3,4 It influenza, particularly if they have a history of
usually resolves within a few days with support- asthma of any degree of severity.
ive care, which includes analgesia, rest and treat-
ment of the underlying medical condition.3,4 References
Inhalation of 100% oxygen is used to replace 1. Soto-Abraham MV, Soriano-Rosas J, Díaz-Quiñónez A, et al.
Pathological changes associated with the 2009 H1N1 virus.
nitrogen in the escaped air with oxygen; nitrogen N Engl J Med 2009;361:2001-3.
is absorbed slowly by capillaries while oxygen is 2. Hasegawa M, Hashimoto K, Morozumi M, et al. Spontaneous
pneumomediastinum complicating pneumonia in children
absorbed rapidly. Although oxygen has been infected with the 2009 pandemic influenza A (H1N1) virus. Clin
suggested as a potential treatment for sponta- Microbiol Infect 2010;16:195-9.
neous pneumomediastinum in children, the evi- 3. Bullaro FM, Bartoletti SC. Spontaneous pneumomediastinum in
children: a literature review. Pediatr Emerg Care 2007;23:28-30.
dence supporting its use is inconclusive.3 It was 4. Caceres M, Ali SZ, Braud R, et al. Spontaneous pneumomedi-
used in the care of two of our patients. Oral astinum: a comparative study and review of the literature. Ann
Thorac Surg 2008;86:962-6.
intake can be discontinued if there is respiratory 5. O’Riordan S, Barton M, Yau Y, et al. Risk factors and outcomes
distress or suspicion of esophageal perforation.4 among children admitted to hospital with pandemic H1N1
influenza. CMAJ 2010;182:39-44.
Serial chest radiographs are not recom-
mended unless there is a deterioration in the Affiliations: From the Department of Pediatrics, Children’s
patient’s condition; instead, clinical status may Hospital of Eastern Ontario, Ottawa, Ont.
be used to indicate improvement or resolution.3
Contributors: All authors contributed to the conception and
Expert opinion recommends avoiding activities design of the manuscript. Sharmila Udupa, Tahir Hameed
in the recovery period that increase the risk of and Tom Kovesi drafted the article. All authors critically
developing a pneumomediastinum, such as revised the manuscript for important intellectual content and
approved the final version submitted for publication.
excessive physical exercise or playing of a wind
instrument.3
The section Cases presents brief case reports
Spontaneous pneumomediastinum and that convey clear, practical lessons. Preference
pandemic (H1N1) influenza is given to common presentations of important
As mentioned previously, Hasegawa and col- rare conditions, and important unusual presen-
leagues recently reported on two Japanese chil- tations of common problems. Articles start
with a case presentation (500 words maxi-
dren with pandemic (H1N1) influenza and pneu-
mum), and a discussion of the underlying con-
momediastinum.2 The patients were six and eight
dition follows (1000 words maximum). Gener-
years of age, and neither had a history of asthma.
ally, up to five references are permitted and
Soto-Abraham and coworkers reported that visual elements (e.g., tables of the differential
pathologic features of fatal pandemic (H1N1) diagnosis, clinical features or diagnostic
influenza included hemorrhage and necrosis of approach) are encouraged. Written consent
the upper respiratory tract and necrosis of the from patients for publication of their story is a
bronchiolar walls.1 Air leak associated with this necessity and should accompany submissions.
infection could be due to airway necrosis, severe See information for authors at www.cmaj.ca.
cough or both. However, there are no reports of

222 CMAJ, February 8, 2011, 183(2)