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Ann Thorac Surg 2004;78:983-986
© 2004 The Society of Thoracic Surgeons
a Department of General Thoracic Surgery, K.A.T. General Hospital of Attica, Kifissia, Greece
Accepted for publication March 2, 2004.
* Address reprint requests to Dr Mihos, 107A Thermopilon St, 15235 Vrilissia, Greece
pmihos{at}otenet.gr
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Abstract |
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METHODS: Between January 1991 and December 2002, 10 patients were admitted with spontaneous pneumomediastinum related to sporting activities. We retrospectively reviewed their medical records with regard to predisposing factors, clinical presentation, diagnostic evaluation, and outcome.
RESULTS: The mean age of our patients was 18.9 years (range 15 to 25 years). Retrosternal chest pain was the most common symptom (90%), and subcutaneous emphysema the most common physical finding (90%). Hamman's sign was present in 9 patients. In all 10 patients, physical exertion during sports was the only implicating factor (scuba diving in 4 patients, basketball in 2, soccer in 3, and volleyball in 1). All patients were treated conservatively. Complete resorption of the pneumomediastinum occurred in 3 to 8 days. Hospital stay ranged from 2 to 6 days (mean 3.8 days). Follow-up was complete in 8 patients (80%), and ranged from 6 to 84 months (mean 35 months). Only 1 recurrence of pneumomediastinum was found that was treated similarly.
CONCLUSIONS: Spontaneous pneumomediastinum after sporting activities is a benign disease that generally resolves without clinical sequelae. Restriction of physical and athletic activity after the first episode is unnecessary, the only exception being that of scuba diving.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Hamman was the first to describe SPM in 1939 [3]. Hamman's sign is the finding of audible crepitus occurring with the heartbeat on chest auscultation, because of the mediastinal air.
The purpose of our study was to report on 10 patients presenting to the emergency department of our hospital with radiologic-evident free air in the mediastinum after an athletic game or activity (sports-related pneumomediastinum, sp-r PM). We attempted to determine predisposing factors, clinical presentation, diagnostic evaluation, and outcome.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Anxiety during examination was evident in all patients. Subcutaneous emphysema was the most common finding (9 of 10 patients, 90%), consisting of swelling in the neck (7 of the 9 patients, 77.7%) or swelling in the chest and neck (2 of the 9 patients, 22.2%). Hamman's sign was also present in 9 of the 10 patients (90%). Physical examination was unrevealing in 1 patient.
The diagnosis of pneumomediastinum was established in all patients by chest radiography showing free mediastinal air (Figs 1 and 2). In most patients the air extended to the anterior cervical region. Computed tomography (CT) scan of the neck and chest was performed in all patients to exclude underlying pulmonary or mediastinal disease; small bullae at the lung apexes were identified in 2 patients by CT scan. Cardiology evaluation was performed in all patients to differentiate pericarditis or other cardiac disease. Electrocardiograms were unrevealing in all but 1 patient in whom a T-wave inversion, which lasted for 2 days, was observed. Blood gas analysis performed in all patients on admission was within normal limits. Esophageal study with a water-soluble contrast material was performed in the 2 patients who presented with mild-to-moderate dysphagia, to rule out esophageal perforation.
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All patients were closely observed with serial chest roentgenograms in our department. They were advised to rest and avoid maneuvers that would create forced expiration. Lengthy inhalation of oxygen was used to facilitate the absorption of the mediastinal air ("nitrogen washout").
The length of hospital stay ranged from 2 to 6 days (mean 3.8 days). Complete resorption of mediastinal air occurred in 3 to 8 days (mean 4 days).
Follow-up was complete in 8 patients (80%) and ranged from 6 to 84 months (mean 35 months). One patient experienced a recurrence of pneumomediastinum, unrelated to physical effort, 26 months after the first episode. He was treated in a similar fashion. We are not aware of any other long-term sequelae.
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Comment |
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Spontaneous pneumomediastinum results from increased intra-alveolar pressure in blebs or alveoli, causing ruptures that allow bubbles of air to dissect along vascular sheaths and connective tissue planes to the mediastinum [6]. The sudden increase in intra-alveolar pressure is usually initiated by cough or expiration against a closed glottis.
Spontaneous pneumomediastinum is a rare condition with a reported incidence ranging from 1 in 800 to 1 in 42,000 of all patients presenting at hospital emergency units [7–11]. A higher incidence has been noted in military hospitals [9]. We found an incidence of 1 in 3406 patients, and agree with others who report that SPM is underdiagnosed in patients with isolated chest pain [11–13].
It is important that clinicians are aware of this entity when they examine a young individual complaining of a sudden chest pain without evidence of pneumothorax in the chest roentgenogram. In ambulatory patients, SPM may be secondary to asthma, inhalation drug use, labor, coughing, forceful straining during exercise, or other activities associated with a Valsalva maneuver [14].
Athletic action or athletic competition has been reported to cause pneumomediastinum. Morgan and Henderson [15] speculated that shock to the chest wall during a football game or soccer could cause pneumomediastinum. In our series, scuba diving (4 of 10 patients) and soccer (3 of 10 patients) were the two most commonly encountered predisposing sporting activities; and similar to other reports, chest pain was the most frequent presenting complaint. We noticed a delay in presentation to the emergency department ranging from 1 to 18 hours, probably due to the patients' good physical condition and because an athlete may not associate symptoms with a specific traumatic event during sports. For this reason, the physician must ask athletes explicitly about the possibility of a sustained trauma during sports.
Once pneumomediastinum is suspected, the diagnosis can be confirmed by chest roentgenogram. Daily chest roentgenograms are recommended to monitor resolution of air. Associated pneumothorax must be looked for, with the patient in the lateral decubitus position rather than during forced expiration, which may worsen pneumomediastinum [16].
When chest roentgenogram findings are inconclusive, CT scan appears to be necessary to establish a correct diagnosis [17]. We have also found CT scan useful to exclude any underlying pulmonary disease, such as the multiple small lung bullae that occurred in 2 of our patients.
Increased awareness of the diverse clinical manifestations of sp-r PM and its benign self-limited course may obviate unnecessary diagnostic and therapeutic interventions. If the physician suspects esophageal rupture, study with a water-soluble contrast material or esophagoscopy should be performed. Barium should be avoided in patients with possible SPM because of the risk of severe mediastinitis if a leak is present. In contrast to Gerazounis and colleagues [18], we do not routinely perform a contrast esophageal study to exclude esophageal rupture. Furthermore, in agreement with Jougon and associates [19], in patients presenting with fever, leukocytosis, hypotension, pleural effusion, or other worrisome signs and symptoms, we would rather use a rigid than a flexible esophagoscopy so as to avoid turning a contained esophageal perforation into a noncontained perforation. Similarly, unless we have a strong suspicion for a tracheobronchial rupture we avoid inducing cough by the use of bronchoscopy. Moreover, Yellin and colleagues [11] recommended that young, healthy patients admitted with sudden chest pain or shortness of breath, with free air in the mediastinum but no pneumothorax, require only observation.
Conservative treatment of SPM consists of careful observation, bed rest, analgesics, and administration of oxygen. The practice of "nitrogen washout" is based on the principle of the partial pressure of gases in a mixture and equilibrium of gases across a permeable membrane. With an increase in inspired oxygen, nitrogen is diluted in the inspired air, creating a gradient between interstitial air (nitrogen-rich) and tracheobronchial air (nitrogen-poor). Consequently, nitrogen travels out of the interstitium down its concentration gradient into the tracheobronchial tree, resulting in resorption [20–22].
Sports-related pneumomediastinum is a benign condition that generally resolves, without sequelae, within 3 to 15 days [23]. In our study, hospitalization ranged from 2 to 6 days and complete resorption of mediastinal air occurred in 3 to 8 days. We encountered only one recurrence that was also treated conservatively. Follow-up was complete in 8 patients (80%), and ranged from 6 to 84 months (mean 35 months). Case reports of recurrent idiopathic and sp-r PM have also been reported [7, 10]. After recovery, restriction of exercise and avoidance of possible predisposing factors is unnecessary, except that avoiding scuba diving may be prudent [7, 11, 20, 24].
In conclusion, SPM is a possibly underdiagnosed benign entity occurring in young and otherwise healthy patients. A correlation of SPM to sporting activities should also be considered in the clinical evaluation of athletes presenting with sudden chest pain or dyspnea. The disorder is usually self-limited and treated conservatively. Assessment should be individualized depending on the patient history and clinical presentation. The diagnosis is established by plain chest roentgenogram. A CT scan of the chest is a valuable means of ruling out underlying pathology. Endoscopic procedures should not be recommended routinely.
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References |
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This article has been cited by other articles:
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  M. Caceres, S. Z. Ali, R. Braud, D. Weiman, and H. E. Garrett Jr Spontaneous Pneumomediastinum: A Comparative Study and Review of the Literature Ann. Thorac. Surg., September 1, 2008; 86(3): 962 - 966. [Abstract] [Full Text] [PDF]
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 J. S. Kwon, M. G. Blum, and R. Kalhan A 23-Year-Old Woman With Sudden-Onset Dyspnea and Chest Pain Penetrating to the Back Chest, February 1, 2008; 133(2): 574 - 578. [Full Text] [PDF]
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 S. H. Loring, C. R. O'Donnell, J. P. Butler, P. Lindholm, F. Jacobson, and M. Ferrigno Transpulmonary pressures and lung mechanics with glossopharyngeal insufflation and exsufflation beyond normal lung volumes in competitive breath-hold divers J Appl Physiol, March 1, 2007; 102(3): 841 - 846. [Abstract] [Full Text] [PDF]
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