ORIGINAL ARTICLE
Spontaneous Pneumomediastinum: Analysis of 62 Consecutive Adult Patients

https://doi.org/10.4065/84.5.417Get rights and content

OBJECTIVE

To clarify the clinical presentation and course of patients with spontaneous pneumomediastinum (SP) and to determine the usefulness of diagnostic testing in these patients.

PATIENTS AND METHODS

We conducted a retrospective review of 62 consecutive adult patients (age ≥18 years) diagnosed as having SP during an 11-year period from July 1, 1997, to June 30, 2008. The study cohort included 41 men and 21 women (median age, 30 years; interquartile range, 20-69 years).

RESULTS

Among the 62 study patients, the most common presenting symptoms were chest pain (39 patients [63%]), cough (28 [45%]), and dyspnea (27 [44%]). Preexisting lung diseases were identified in 27 patients (44%) and included interstitial lung disease, asthma, lung malignancies, bronchiolitis obliterans syndrome, chronic obstructive pulmonary disease, bronchiectasis, and cystic lung lesions. The initial diagnosis of SP was achieved by chest radiography in 52 patients (84%); the remaining cases were diagnosed by computed tomography. Forty-seven patients (76%) were hospitalized for a median duration of 2.5 days. Additional diagnostic procedures were performed in 27 patients (44%) and included contrast esophagography, bronchoscopy, and esophagogastroduodenoscopy; however, they did not yield a pathologic cause in any patient. Pneumothorax was identified in 20 patients (32%), but less than one-third of these patients underwent chest tube thoracostomy. No episodes of mediastinitis or sepsis occurred. Recurrence of SP was seen in 1 patient, and thoracoscopic surgery was performed in 1 patient for persistent air leak (pneumothorax).

CONCLUSION

Spontaneous pneumomediastinum was associated with a relatively benign clinical course; however, pneumothorax was seen in 32% of cases. Diagnostic testing to determine a pathologic cause yielded little clinically relevant information in these patients.

Section snippets

PATIENTS AND METHODS

The study was conducted at Mayo Clinic's site in Rochester, MN. A computer-assisted search was performed to identify all adult cases of SP diagnosed during an 11-year period from July 1, 1997, to June 30, 2008. Medical records were reviewed to exclude cases of traumatic and iatrogenic pneumomediastinum, including those associated with chest trauma, cardiopulmonary resuscitation, mechanical ventilation, or any surgical/interventional procedures. Neonatal and pediatric patients (<18 years) were

RESULTS

Demographic data for the 62 patients, including 41 men and 21 women, are outlined in Table 1. The median age at diagnosis of SP was 30 years (interquartile range [IQR], 20-69 years). Of the 62 study patients, 21 (34%) were active or past smokers at the time of diagnosis. Pneumomediastinum was diagnosed in these patients most often in the emergency department (49 patients [79%]) but also in the ICU (7 patients [11%]), outpatient clinic (5 patients [8%]), and hospital ward (1 patient [2%]).

DISCUSSION

Spontaneous pneumomediastinum is an uncommon disorder that can be encountered in a variety of clinical settings. The pathophysiology of SP was delineated by Macklin8 in his experimental animal model. His work showed how alveolar hyperinflation causes alveolar damage with subsequent leakage of air from alveolar spaces into the interstitium followed by proximal migration of air toward the hilum and the mediastinum alongside the pulmonary vasculature. Once the air reaches the mediastinum, it

CONCLUSION

Spontaneous pneumomediastinum is associated with a relatively benign clinical course but may be complicated by the occurrence of pneumothorax in 32% of patients, a frequency higher than has been previously reported. In the absence of a concomitant pneumothorax or severe illness requiring inpatient care, patients with SP could probably be treated on an outpatient basis. The clinical course of patients with SP is influenced more by the severity of the underlying disorder (eg, advanced

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