Pneumomediastinum

Case contributed by Frank Gaillard

Presentation

Collapse at home. Intubated at the scene by paramedics. CT demonstrated a subdural hemorrhage (not shown) which was evacuated. Patient now in ICU.

Patient Data

Age: 80 years
Gender: Male

Chest x-ray

x-ray

Chest radiograph demonstrates the patient to be intubated with a right internal jugular central venous catheter and a nasogastric tube in situ. Extensive pneumomediastinum is seen, extending into the neck and outlining the pericardium.

CT chest

ct

CT of the chest demonstrates endotracheal tube, nasogastric tube and right internal jugular central line appropriately positioned.
Extensive pneumomediastinum and subcutaneous emphysema noted. Contained contour irregularity in the distal trachea, just above the carina measures 1 cm transverse x 3.5 cm long, is likely to be the source of the gas.

Small bilateral effusions. No pneumothorax. Minor patchy air space opacity, in keeping with atelectasis. There are multiple small nodules, 4 mm or less in both lungs. Heart and aorta within normal limits on this unenhanced CT.

Conclusion:

Distal tracheal contour irregularity. It is difficult to precisely measure the size of the defect, which would be better assessed on bronchoscopy.

Case Discussion

This patient was treated conservatively and gradually improved.

Tracheal trauma is often iatrogenic, often the result if difficult emergency intubation. In many cases they can be treated conservatively (as in this case) although clearly positive pressure ventilation can be problematic.

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