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Subcutaneous and Mediastinal Emphysema: Pathophysiology, Diagnosis, and Management

Subcutaneous and Mediastinal Emphysema: Pathophysiology, Diagnosis, and Management Abstract • Subcutaneous emphysema and pneumomediastinum occur frequently in critically ill patients in association with blunt or penetrating trauma, soft-tissue infections, or any condition that creates a gradient between intra-alveolar and perivascular interstitial pressures. A continuum of fascial planes connects cervical soft tissues with the mediastinum and retroperitoneum, permitting aberrant air arising in any one of these areas to spread elsewhere. Diagnosis is made in the appropriate clinical setting by careful physical examination and inspection of the chest roentgenogram. While the presence of air in subcutaneous or mediastinal tissue is not dangerous in itself, prompt recognition of the underlying cause is essential. Certain trauma-related causes may require surgical intervention, but the routine use of chest tubes, tracheostomy, or mediastinal drains is not recommended. (Arch Intern Med 1984;144:1447-1453) References 1. Killen DA, Gobbel WG: Spontaneous Pneumothorax . London, Churchill Livingstone, 1968. 2. Sahn SA: Pneumothorax , in Sahn SA (ed): Pulmonary Emergencies . New York, Churchill Livingstone, 1982, pp 239-273. 3. Green R, McCloud TC, Stark P: Pneumothorax. Semin Roentgenol 1977;12:313-325.Crossref 4. Oliphant M, Wiot JF, Whalen JP: The cervicothoracic continuum. Radiology 1976;120:257-262.Crossref 5. Pearse HE: Mediastinitis following cervical suppuration. Ann Surg 1938;108:588-604.Crossref 6. Moncada R, Warpeha R, Pickleman J, et al: Mediastinitis from odontogenic and deep cervical infection. Chest 1978;73:497-500.Crossref 7. Thawley SE: Air in the neck. Laryngoscope 1974;9:1445-1453.Crossref 8. Marchand P: The anatomy and applied anatomy of the mediastinal fascia. Thorax 1951;6:359-368.Crossref 9. Meyers MA: Radiological features of the spread and localization of extraperitoneal gas and their relationship to its source. Diagn Radiol 1974;111:17-26. 10. Kleinman PK, Brill PW, Whalen JP: Anterior pathway for transdiaphragmatic extension of pneumomediastinum. AJR 1978;131:271-275.Crossref 11. Heitzman ER: The Mediastinum: Radiologic Correlations With Anatomy and Physiology . St Louis, CV Mosby Co, 1977. 12. Namdaran F, Dutz W, Ovasepian A: Pneumatosis cystoides intestinalis in Iran. Gut 1979;20:16-21.Crossref 13. Shallal JA, Vanheenden JA, Bartholomew LG, et al: Pneumatosis cystoides intestinalis. Mayo Clin Proc 1974;49:180-184. 14. Romfh RF: Subcutaneous and mediastinal emphysema. Ann Emerg Med 1972;1:35-37. 15. Hirsch M, Abramowitz HB, Shapira S, et al: Hypopharyngeal injury as a result of attempted endotracheal intubation. Radiology 1978;128:37-39.Crossref 16. Wiot JF: Tracheobronchial trauma. Semin Roentgenol 1983;18:15-22.Crossref 17. Curci JJ, Horman MJ: Boerhaave's syndrome: Importance of early diagnosis and treatment. Ann Surg 1976;183:401-408.Crossref 18. Rogers LF, Puig AW, Dooley BN, et al: Diagnostic considerations in mediastinal emphysema: A pathophysiologic-roentgenologic approach to Boerhaave's syndrome and spontaneous pneumomediastinum. AJR 1972;115:495-511.Crossref 19. Kirsch MM, Sloane H: Blunt Chest Trauma: General Principles of Management . Boston, Little Brown & Co, 1977. 20. Robertson HT, Lakshminarayan S, Hudson LD: Lung injury following a 50-metre fall into water. Thorax 1978;33:175-180.Crossref 21. Bertelson S, Howitz P: Injuries of the trachea and bronchi. Thorax 1972;27:188-194.Crossref 22. Kirsch MM, Orringer MB, Behrendt DM, et al: Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg 1976;22:93-101.Crossref 23. Mogan GR, Sachar DB, Bauer J, et al: Toxic megacolon in ulcerative colitis complicated by pneumomediastinum: Report of two cases. Gastroenterology 1980;79:559-562. 24. Lezak MB, Goldhamer M: Retroperitoneal emphysema after colonoscopy. Gastroenterology 1974;66:118-120. 25. Walker HC, Nivatvongs S, Ansel HJ, et al: Massive extraperitoneal air in a 71-year-old woman: Occurrence during a radiological study. JAMA 1983;248:1375-1376.Crossref 26. Atcheson SG, Peterson GV, Fred HL: Ill effects of cardiac resuscitation: Report of two unusual cases. Chest 1975;67:615-616.Crossref 27. McClure JN, Skardasos GM, Brown JM: Cardiac arrest in the operating area. Am Surg 1972;38:241-242. 28. Agia G, Hurst E: Pneumomediastinum following the Heimlich maneuver. Ann Emerg Med 1979;8:473-475. 29. Munsell WP: Pneumomediastinum. JAMA 1967;202:129-133.Crossref 30. Laennec RTH: A Treatise on the Diseases of the Chest and Mediate Auscultation , Forbes J (trans). London, T & G Underwood, 1821. 31. Macklin MT, Macklin CC: Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: An interpretation of the clinical literature in the light of laboratory experiment. Medicine 1944;23:281-352.Crossref 32. Macklin CC: Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: Clinical implications. Arch Intern Med 1939;64:913-926.Crossref 33. Westcott JL, Cole SR: Interstitial pulmonary emphysema in children and adults: Roentgenographic features. Radiology 1974;111:367-378.Crossref 34. Kumar A, Pontoppidan H, Falk KI, et al: Pulmonary barotrauma during mechanical ventilation. Crit Care Med 1973;1:181-186.Crossref 35. Hamman L: Spontaneous mediastinal emphysema. Johns Hopkins Med J 1939;64:1-21. 36. Kusch MM, Orvald TO: Mediastinal and subcutaneous emphysema complicating acute bronchial asthma. Chest 1970;57:580-581.Crossref 37. Zegel HG, Miller WT: Subcutaneous emphysema in a young man. JAMA 1979;241:1273-1274.Crossref 38. Steffey WR, Cohn AM: Spontaneous subcutaneous emphysema of the head, neck and mediastinum. Arch Otolaryngol 1974;100:32-35.Crossref 39. Cooley JC, Gillespie JB: Mediastinal emphysema: Pathogenesis and management. Chest 1966;49:104-108.Crossref 40. Wohl MEB, Chernick V: Bronchiolitis. Am Rev Respir Dis 1978; 118:759-781. 41. Gapany-Gapanavicius M, Yellin A, Almog S, et al: Pneumomediastinum: A complication of chlorine exposure from mixing household cleaning agents. JAMA 1983;248:349-350.Crossref 42. Janetos GP, Ochsner SF: Bilateral pneumothorax in metastatic osteogenic sarcoma. Am Rev Respir Dis 1963;88:73-76. 43. Gay BB: Radiologic evaluation of the nontraumatized child with respiratory distress. Radiol Clin North Am 1978;16:91-112. 44. Popovich J, Babcock R: Intraluminal blood cast causing obstructive emphysema and recurrent pneumothorax. Crit Care Med 1982;10:482-483.Crossref 45. Greenberg LF, Benham Kahn S: Klebsiella pneumonia with pneumothorax, pneumomediastinum and pneumoperitoneum. Chest 1963;43: 546-550.Crossref 46. Newton NI, Adams AP: Excessive airway pressure during anaesthesia. Anaesthesia 1978;33:689-699.Crossref 47. Zwillich CW, Pierson DJ, Creagh CE, et al: Complications of assisted ventilation: A prospective study of 354 consecutive episodes. Am J Med 1974;57:161-174.Crossref 48. Rohlfing BM, Webb WR, Schlobohm RM: Ventilator-related extraalveolar air in adults. Radiology 1976;121:25-31.Crossref 49. Bone RC, Francis PB, Pierce AK: Pulmonary barotrauma complicating positive end-expiratory pressure, abstracted. Am Rev Respir Dis 1975;111:921. 50. Peterson GW, Baier H: Incidence of pulmonary barotrauma in a medical ICU. Crit Care Med 1983;11:67-69.Crossref 51. Nennhaus HP, Hushong J, Julian OC: Alveolar and pleural rupture: Hazards of positive pressure respiration. Arch Surg 1967;94:136-141.Crossref 52. Varkey B, Kory RC: Mediastinal and subcutaneous emphysema following pulmonary function tests. Am Rev Respir Dis 1973;108:1393-1396. 53. Millard CE: Pneumomediastinum. Chest 1969;56:297-300.Crossref 54. Morgan EJ, Henderson DA: Pneumomediastinum as a complication of athletic competition. Thorax 1981;36:155-156.Crossref 55. Girard DE, Carlson V, Natelson EA, et al: Pneumomediastinum in diabetic ketoacidosis: Comments on mechanism, incidence, and management. Chest 1971;60:455-459.Crossref 56. Miller WE, Spiekerman RE, Hepper NG: Pneumomediastinum resulting from performing Valsalva maneuvers during marijuana smoking. Chest 1972;62:233-234.Crossref 57. Vosk A, Houston CS: Mediastinal emphysema in mountain climbers: Report of two cases and review. Heart Lung 1977;6:799-805. 58. Elliot DH, Harrison JAB, Barnard EEP: Clinical and radiologic features of 88 cases of decompression barotrauma , in Schilling CW, Beckett MW (eds): Underwater Physiology VI . Bethesda, Md, Federation of American Societies for Experimental Biology, 1978, pp 527-535. 59. Grosfeld JL, Clatworthy HW, Frye TR: Surgical therapy in neonatal air-block syndrome. J Thorac Cardiovasc Surg 1970;60:392-401. 60. Jewett TC, Adler RH, Taheri SA: Tension pneumomediastinum in the newborn. J Thorac Cardiovasc Surg 1962;43:540-547. 61. Van Stiegmann G, Brantigan CO, Hopeman AR: Tension pneumomediastinum. Arch Surg 1977;112:1212-1215.Crossref 62. Webb WR, Johnston JH, Geisler JW: Pneumomediastinum: Physiologic observations. J Thorac Cardiovasc Surg 1958;35:309-315. 63. Bodey GP: Medical mediastinal emphysema. Ann Intern Med 1961;54:44-56. 64. Littmann D: Electrocardiographic phenomena associated with spontaneous pneumothorax and mediastinal emphysema. Am J Med Sci 1946;212:682-690.Crossref 65. Levin B: The continuous diaphragm sign. Radiology 1973;24:337-338. 66. Oh KS, Fleischner FG, Wyman SM: Characteristic pulmonary finding in traumatic complete transection of a main-stem bronchus. Radiology 1969;92:371-372.Crossref 67. Hood AI, Sloan HE: Injuries of the trachea and major bronchi. J Thorac Cardiovasc Surg 1959;38:458-480. 68. Grover FL, Ellestad C, Arom KV, et al: Diagnosis and management of major tracheobronchial injuries. Ann Thorac Surg 1979;28:384-391.Crossref 69. Woodring JH, Fried AM, Hatfield DR, et al: Fractures of the first and second ribs: Predictive value for arterial and bronchial injury. AJR 1982;138:211-215.Crossref 70. Hillman KM: Pneumoperitoneum: A review. Crit Care Med 1982;10: 476-481.Crossref 71. Rydell JR: Emergency cervical mediastinotomy for massive mediastinal emphysema. Arch Surg 1955;70:647-653.Crossref 72. Glauser FL, Bartlett RH: Pneumoperitoneum in association with pneumo-thorax. Chest 1974;66:536-540.Crossref 73. Stein AL, Lane E: A new treatment modality for pneumoperitoneum associated with mechanical ventilation. Chest 1982;81:519-520.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Subcutaneous and Mediastinal Emphysema: Pathophysiology, Diagnosis, and Management

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American Medical Association
Copyright
Copyright © 1984 American Medical Association. All Rights Reserved.
ISSN
0003-9926
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1538-3679
DOI
10.1001/archinte.1984.00350190143024
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Abstract

Abstract • Subcutaneous emphysema and pneumomediastinum occur frequently in critically ill patients in association with blunt or penetrating trauma, soft-tissue infections, or any condition that creates a gradient between intra-alveolar and perivascular interstitial pressures. A continuum of fascial planes connects cervical soft tissues with the mediastinum and retroperitoneum, permitting aberrant air arising in any one of these areas to spread elsewhere. Diagnosis is made in the appropriate clinical setting by careful physical examination and inspection of the chest roentgenogram. While the presence of air in subcutaneous or mediastinal tissue is not dangerous in itself, prompt recognition of the underlying cause is essential. Certain trauma-related causes may require surgical intervention, but the routine use of chest tubes, tracheostomy, or mediastinal drains is not recommended. (Arch Intern Med 1984;144:1447-1453) References 1. Killen DA, Gobbel WG: Spontaneous Pneumothorax . London, Churchill Livingstone, 1968. 2. Sahn SA: Pneumothorax , in Sahn SA (ed): Pulmonary Emergencies . New York, Churchill Livingstone, 1982, pp 239-273. 3. Green R, McCloud TC, Stark P: Pneumothorax. Semin Roentgenol 1977;12:313-325.Crossref 4. Oliphant M, Wiot JF, Whalen JP: The cervicothoracic continuum. Radiology 1976;120:257-262.Crossref 5. Pearse HE: Mediastinitis following cervical suppuration. Ann Surg 1938;108:588-604.Crossref 6. Moncada R, Warpeha R, Pickleman J, et al: Mediastinitis from odontogenic and deep cervical infection. Chest 1978;73:497-500.Crossref 7. Thawley SE: Air in the neck. Laryngoscope 1974;9:1445-1453.Crossref 8. Marchand P: The anatomy and applied anatomy of the mediastinal fascia. Thorax 1951;6:359-368.Crossref 9. Meyers MA: Radiological features of the spread and localization of extraperitoneal gas and their relationship to its source. Diagn Radiol 1974;111:17-26. 10. Kleinman PK, Brill PW, Whalen JP: Anterior pathway for transdiaphragmatic extension of pneumomediastinum. AJR 1978;131:271-275.Crossref 11. Heitzman ER: The Mediastinum: Radiologic Correlations With Anatomy and Physiology . St Louis, CV Mosby Co, 1977. 12. Namdaran F, Dutz W, Ovasepian A: Pneumatosis cystoides intestinalis in Iran. Gut 1979;20:16-21.Crossref 13. Shallal JA, Vanheenden JA, Bartholomew LG, et al: Pneumatosis cystoides intestinalis. Mayo Clin Proc 1974;49:180-184. 14. Romfh RF: Subcutaneous and mediastinal emphysema. Ann Emerg Med 1972;1:35-37. 15. Hirsch M, Abramowitz HB, Shapira S, et al: Hypopharyngeal injury as a result of attempted endotracheal intubation. Radiology 1978;128:37-39.Crossref 16. Wiot JF: Tracheobronchial trauma. Semin Roentgenol 1983;18:15-22.Crossref 17. Curci JJ, Horman MJ: Boerhaave's syndrome: Importance of early diagnosis and treatment. Ann Surg 1976;183:401-408.Crossref 18. Rogers LF, Puig AW, Dooley BN, et al: Diagnostic considerations in mediastinal emphysema: A pathophysiologic-roentgenologic approach to Boerhaave's syndrome and spontaneous pneumomediastinum. AJR 1972;115:495-511.Crossref 19. Kirsch MM, Sloane H: Blunt Chest Trauma: General Principles of Management . Boston, Little Brown & Co, 1977. 20. Robertson HT, Lakshminarayan S, Hudson LD: Lung injury following a 50-metre fall into water. Thorax 1978;33:175-180.Crossref 21. Bertelson S, Howitz P: Injuries of the trachea and bronchi. Thorax 1972;27:188-194.Crossref 22. Kirsch MM, Orringer MB, Behrendt DM, et al: Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thorac Surg 1976;22:93-101.Crossref 23. Mogan GR, Sachar DB, Bauer J, et al: Toxic megacolon in ulcerative colitis complicated by pneumomediastinum: Report of two cases. Gastroenterology 1980;79:559-562. 24. Lezak MB, Goldhamer M: Retroperitoneal emphysema after colonoscopy. Gastroenterology 1974;66:118-120. 25. Walker HC, Nivatvongs S, Ansel HJ, et al: Massive extraperitoneal air in a 71-year-old woman: Occurrence during a radiological study. JAMA 1983;248:1375-1376.Crossref 26. Atcheson SG, Peterson GV, Fred HL: Ill effects of cardiac resuscitation: Report of two unusual cases. Chest 1975;67:615-616.Crossref 27. McClure JN, Skardasos GM, Brown JM: Cardiac arrest in the operating area. Am Surg 1972;38:241-242. 28. Agia G, Hurst E: Pneumomediastinum following the Heimlich maneuver. Ann Emerg Med 1979;8:473-475. 29. Munsell WP: Pneumomediastinum. JAMA 1967;202:129-133.Crossref 30. Laennec RTH: A Treatise on the Diseases of the Chest and Mediate Auscultation , Forbes J (trans). London, T & G Underwood, 1821. 31. Macklin MT, Macklin CC: Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: An interpretation of the clinical literature in the light of laboratory experiment. Medicine 1944;23:281-352.Crossref 32. Macklin CC: Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: Clinical implications. Arch Intern Med 1939;64:913-926.Crossref 33. Westcott JL, Cole SR: Interstitial pulmonary emphysema in children and adults: Roentgenographic features. Radiology 1974;111:367-378.Crossref 34. Kumar A, Pontoppidan H, Falk KI, et al: Pulmonary barotrauma during mechanical ventilation. Crit Care Med 1973;1:181-186.Crossref 35. Hamman L: Spontaneous mediastinal emphysema. Johns Hopkins Med J 1939;64:1-21. 36. Kusch MM, Orvald TO: Mediastinal and subcutaneous emphysema complicating acute bronchial asthma. Chest 1970;57:580-581.Crossref 37. Zegel HG, Miller WT: Subcutaneous emphysema in a young man. JAMA 1979;241:1273-1274.Crossref 38. Steffey WR, Cohn AM: Spontaneous subcutaneous emphysema of the head, neck and mediastinum. Arch Otolaryngol 1974;100:32-35.Crossref 39. Cooley JC, Gillespie JB: Mediastinal emphysema: Pathogenesis and management. Chest 1966;49:104-108.Crossref 40. Wohl MEB, Chernick V: Bronchiolitis. Am Rev Respir Dis 1978; 118:759-781. 41. Gapany-Gapanavicius M, Yellin A, Almog S, et al: Pneumomediastinum: A complication of chlorine exposure from mixing household cleaning agents. JAMA 1983;248:349-350.Crossref 42. Janetos GP, Ochsner SF: Bilateral pneumothorax in metastatic osteogenic sarcoma. Am Rev Respir Dis 1963;88:73-76. 43. Gay BB: Radiologic evaluation of the nontraumatized child with respiratory distress. Radiol Clin North Am 1978;16:91-112. 44. Popovich J, Babcock R: Intraluminal blood cast causing obstructive emphysema and recurrent pneumothorax. Crit Care Med 1982;10:482-483.Crossref 45. Greenberg LF, Benham Kahn S: Klebsiella pneumonia with pneumothorax, pneumomediastinum and pneumoperitoneum. Chest 1963;43: 546-550.Crossref 46. Newton NI, Adams AP: Excessive airway pressure during anaesthesia. Anaesthesia 1978;33:689-699.Crossref 47. Zwillich CW, Pierson DJ, Creagh CE, et al: Complications of assisted ventilation: A prospective study of 354 consecutive episodes. Am J Med 1974;57:161-174.Crossref 48. Rohlfing BM, Webb WR, Schlobohm RM: Ventilator-related extraalveolar air in adults. Radiology 1976;121:25-31.Crossref 49. Bone RC, Francis PB, Pierce AK: Pulmonary barotrauma complicating positive end-expiratory pressure, abstracted. Am Rev Respir Dis 1975;111:921. 50. Peterson GW, Baier H: Incidence of pulmonary barotrauma in a medical ICU. Crit Care Med 1983;11:67-69.Crossref 51. Nennhaus HP, Hushong J, Julian OC: Alveolar and pleural rupture: Hazards of positive pressure respiration. Arch Surg 1967;94:136-141.Crossref 52. Varkey B, Kory RC: Mediastinal and subcutaneous emphysema following pulmonary function tests. Am Rev Respir Dis 1973;108:1393-1396. 53. Millard CE: Pneumomediastinum. Chest 1969;56:297-300.Crossref 54. Morgan EJ, Henderson DA: Pneumomediastinum as a complication of athletic competition. Thorax 1981;36:155-156.Crossref 55. Girard DE, Carlson V, Natelson EA, et al: Pneumomediastinum in diabetic ketoacidosis: Comments on mechanism, incidence, and management. Chest 1971;60:455-459.Crossref 56. Miller WE, Spiekerman RE, Hepper NG: Pneumomediastinum resulting from performing Valsalva maneuvers during marijuana smoking. Chest 1972;62:233-234.Crossref 57. Vosk A, Houston CS: Mediastinal emphysema in mountain climbers: Report of two cases and review. Heart Lung 1977;6:799-805. 58. Elliot DH, Harrison JAB, Barnard EEP: Clinical and radiologic features of 88 cases of decompression barotrauma , in Schilling CW, Beckett MW (eds): Underwater Physiology VI . Bethesda, Md, Federation of American Societies for Experimental Biology, 1978, pp 527-535. 59. Grosfeld JL, Clatworthy HW, Frye TR: Surgical therapy in neonatal air-block syndrome. J Thorac Cardiovasc Surg 1970;60:392-401. 60. Jewett TC, Adler RH, Taheri SA: Tension pneumomediastinum in the newborn. J Thorac Cardiovasc Surg 1962;43:540-547. 61. Van Stiegmann G, Brantigan CO, Hopeman AR: Tension pneumomediastinum. Arch Surg 1977;112:1212-1215.Crossref 62. Webb WR, Johnston JH, Geisler JW: Pneumomediastinum: Physiologic observations. J Thorac Cardiovasc Surg 1958;35:309-315. 63. Bodey GP: Medical mediastinal emphysema. Ann Intern Med 1961;54:44-56. 64. Littmann D: Electrocardiographic phenomena associated with spontaneous pneumothorax and mediastinal emphysema. Am J Med Sci 1946;212:682-690.Crossref 65. Levin B: The continuous diaphragm sign. Radiology 1973;24:337-338. 66. Oh KS, Fleischner FG, Wyman SM: Characteristic pulmonary finding in traumatic complete transection of a main-stem bronchus. Radiology 1969;92:371-372.Crossref 67. Hood AI, Sloan HE: Injuries of the trachea and major bronchi. J Thorac Cardiovasc Surg 1959;38:458-480. 68. Grover FL, Ellestad C, Arom KV, et al: Diagnosis and management of major tracheobronchial injuries. Ann Thorac Surg 1979;28:384-391.Crossref 69. Woodring JH, Fried AM, Hatfield DR, et al: Fractures of the first and second ribs: Predictive value for arterial and bronchial injury. AJR 1982;138:211-215.Crossref 70. Hillman KM: Pneumoperitoneum: A review. Crit Care Med 1982;10: 476-481.Crossref 71. Rydell JR: Emergency cervical mediastinotomy for massive mediastinal emphysema. Arch Surg 1955;70:647-653.Crossref 72. Glauser FL, Bartlett RH: Pneumoperitoneum in association with pneumo-thorax. Chest 1974;66:536-540.Crossref 73. Stein AL, Lane E: A new treatment modality for pneumoperitoneum associated with mechanical ventilation. Chest 1982;81:519-520.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 1, 1984

References