Contributor: Megan Hurley MD

Educational Pearls:

What is the mediastinum?

The thoracic cavity is separated into different compartments by membranes
The lungs exist in their own pleural cavities, and the mediastinum is everything in between

The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves.

What is a pneumomediastinum?

How can pneumomediastinum be categorized?

Ex. Stab wound to the trachea
Ex. Boerhaave’s Syndrome of the esophagus, possibly from an endoscopic procedure. This mechanism in particular is a higher risk of infection because not only air but food can accumulate in the mediastinum
Ex. Intubation with a bougie
These will likely need surgical repair

Ex. Forceful inhalation causing microperforations in the trachea. Possibly while inhaling something like drugs
Ex. Bad asthma for similar reasons
Ex. Gas forming bacteria

What happens if you use positive pressure ventilation on a patient with a hole in their trachea?

The positive pressure will force extra air into the mediastinum
The air will move between the layers of subcutaneous tissue and can track up into the neck and face regions recognized as crepitus on exam
This can also cause a tension pneumomediastinum in which the air pressure in the compartment constricts the heart, impeding its ability to fill during diastole
These patients can undergo bronchoscopy because that procedure does not require positive pressure and will not worsen the condition. Endoscopies do require positive pressure so endoscopies are not an option

How is a tension pneumomediastinum treated?

By inserting a needle into the space from below the xiphoid process to allow the air to escape, similar to a pericardiocentesis
As a temporizing measure, if the hole is high enough in the trachea, the intubation can be continued by deliberately pushing the endotracheal tube into the right main bronchus, creating a seal, and only ventilating the right lung while the patient heads to surgery. This is called right-mainstemming.

References

Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. J Intensive Care Soc. 2017 Feb;18(1):52-56. doi: 10.1177/1751143716662665. Epub 2016 Aug 3. PMID: 28979537; PMCID: PMC5606356.
Grewal, J., & Gillaspie, E. A. (2024). Pneumomediastinum. Thoracic surgery clinics, 34(4), 309–319. https://doi.org/10.1016/j.thorsurg.2024.06.001
Underner, M., Perriot, J., & Peiffer, G. (2017). Pneumomédiastin et consommation de cocaïne [Pneumomediastinum and cocaine use]. Presse medicale (Paris, France : 1983), 46(3), 249–262. https://doi.org/10.1016/j.lpm.2017.01.002

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Episode 937: Pneumomediastinum

Emergency Medical Minute