CASE MANAGEMENT CONFERENCE

PNEUMOMEDIASTINUM
SUBCUTANEOUS EMPHYSEMA

Mary Raina Angeli Z. Abad, MD

Charleen Joy A. Beredo, MD
November 25, 2014

OBJECTIVES
General:
To present a case of a patient with Subcutaneous
Emphysema
Specific:
1. To present the history, physical examination findings
and diagnosis of a patient with Subcutaneous
Emphysema
2. To discuss Subcutaneous Emphysema, its presentation,
causes and pathophysiology
3. To discuss the appropriate management for a patient
with Subcutaneous Emphysema

GENERAL DATA

M.J.
45/F
Filipino
Married
Roman Catholic
Born and currently residing in GMA, Cavite
Admitted for the first time at DLSUMC on November 10,
2014 at around 2:00pm

CHIEF COMPLAINT

COUGH

HISTORY OF PRESENT ILLNESS

1 month
PTA

3 weeks
PTA

(+) productive cough with whitish phlegm

(+) intermittent high-grade fever (max=39.0C)
(-) nausea, (-) vomiting, (-) chills, (-) abdominal pain, (-)
chest pain, (-) dyspnea
(+) consult given Cefuroxime 500mg/tab BID x 7 days

Persistence of productive cough and fever

Still no other signs and symptoms noted
(+) consult given Carbocisteine 500mg/tab TID,
Clarithromycin 500mg/tab OD, Salbutamol neb Q8,
Multivitamins

HISTORY OF PRESENT ILLNESS

2 weeks
PTA

1 week
PTA

Persistence of cough and fever

Still no other signs and symptoms were noted
Clarithromycin was continued for another 3 days

Sought consult with a private physician at our institution for

2nd opinion due to persistence of cough and fever
T3, T4, TSH were requested
Cefuroxime 500mg/tab was continued for another week

HISTORY OF PRESENT ILLNESS

3 days
PTA

1 day PTA

(+) enlargement of neck area which gradually progressed

towards facial area
Persistence of cough and fever
(+) consult with private physician given Cefuroxime
500mg/tab, Moxifloxacin 400mg/tab, Metoprolol
100mg/tab, Propylthiouracil 100mg/tab

Persistence of cough and fever

(+) consult at the ER with xray findings of
pneumomediastinum and subcutaneous emphysema
Advised admission but opted HAMA

HISTORY OF PRESENT ILLNESS

DOC

Went back to the ER

Persistence of cough and fever
(+) dyspnea
Progression of increase in the size of the neck and
buccal area hence admitted

PAST MEDICAL HISTORY

(-) hypertension
(-) diabetes mellitus
(-) asthma
(-) PTB
(-) allergies to food or medications
(-) previous hospitalization

FAMILY HISTORY

(-) hypertension
(-) diabetes mellitus
(-) asthma
(-) PTB
(-) cancer
(-) cardiac diseases
(-) renal diseases

PERSONAL AND SOCIAL HISTORY

Non-smoker
Non-alcoholic beverage drinker

MENSTRUAL HISTORY

Menarche: 12 years old

Interval: 28 days
Duration: 4-5 days
Amount: 3-4 pads moderately soaked
Symptoms: None

OB-GYN HISTORY
G4P4 (4004)
No complications noted

REVIEW OF SYSTEMS
General: (+) weakness, (+) loss of appetite, (+) weight
loss (~50%), (-) easy fatigability
Integument: (-) pallor, (+) hyperpigmentation on cheeks
area (~1 year), (-) clubbing of nails, (-) lesions, (-) mass
Head and Neck: (-) dizziness, (-) headache, (-)
lymphadenopathy, (-) distention of veins
Eyes: (-) blurring of vision, (-) icteric sclerae, (-) redness,
(-) discharge
Ears: (-) tinnitus, (-) vertigo, (-) discharge

REVIEW OF SYSTEMS
Nose: (-) epistaxis, (-) discharge, (-) congestion, (-)
colds, (-) obstruction
Mouth and Throat: (-) sore throat, (-) hoarseness, (-)
dysphagia, (-) toothache
Cardiovascular: (-) chest pain, (-) palpitations
GIT: (-) diarrhea, (-) constipation, (-) abdominal pain

REVIEW OF SYSTEMS
GUT: (-) dysuria, (-) frequency, (-) hypogastric pain, (-)
flank pains
Hematologic: (-) easy bruising, (-) easy bleeding
Endocrine: (-) polydipsia, (-) polyphagia, (-) diaphoresis,
(-) heat/cold intolerance
Musculoskeletal: (+) joint pain (~3 years), (-) edema, (-)
fractures
Nervous: (-) paralysis, (-) syncope, (-) tremors, (-)
seizures

PHYSICAL EXAMINATION
General Survey
The patient is well developed, fairly nourished,
conscious, coherent, oriented to time, place and person,
ambulatory, in mild cardiorespiratory distress
Vital Signs
BP = 110/70 mmHg
HR = 108 bpm
RR = 26 cpm
Temp = 37.5C

PHYSICAL EXAMINATION
Integument
There was no pallor, erythema, jaundice. No mass or
lesions were noted. The patient is not febrile to touch.
The skin was neither warm nor cool to touch, no
excessive moisture or dryness and has good skin turgor.

PHYSICAL EXAMINATION
HEENT
(+) crepitus on the cheeks, neck and supraclavicular
area.
(+) erythematous, macular rashes localized on the
cheeks.
(+) asymmetry of the neck and cheeks: R>L.
Parotid glands and thyroid gland were not palpable. No
discharge noted from the eyes, ears and nose. Anicteric
sclerae and pink palpebral conjunctiva were noted. The
tonsils were non-hyperemic and non-hypertrophic

PHYSICAL EXAMINATION
Chest and Lungs
Inspection: There is symmetrical chest expansion. No
mass or lesions were noted. No retractions and
deformities were noted. No use of accessory muscles
were noted.
Palpation: There is noted point tenderness on anterior
chest wall as well as crepitus.
Percussion: Resonant on all lung fields.
Auscultation: There is noted basal crackles on the right
lung field.

PHYSICAL EXAMINATION
Cardiovascular
Inspection: No lesions and precordial bulging were
noted.
Palpation: Apex beat and PMI were both noted at the 5th
ICS LMCL. There were no heaves or thrills.
Auscultation: The heart rate is normal and has regular
rhythm. S1>S2 at the apex and S2>S1 at the base. No
murmurs were noted.

PHYSICAL EXAMINATION
Abdomen
Inspection: The abdomen is flabby and symmetrical. No
lesions, mass, visible pulsations and visible peristalsis
noted. The umbilicus is inverted.
Auscultation: Normoactive bowel sounds (10 bowel
sounds/minute).
Palpation: No tenderness noted.
Percussion: The abdomen was tympanitic all over.

PHYSICAL EXAMINATION
Extremities
There are full and equal peripheral pulses. No edema
and no limitation of movement noted.

PHYSICAL EXAMINATION
Neurologic
The patient is oriented to time, place and person. She
also has good recent, remote and immediate memory.

PHYSICAL EXAMINATION
Cranial Nerves
I
intact
II
(+) direct and consensual pupillary light reflex
III, IV, VI good extraocular muscle movement
V
good masseter contraction
VII
no facial asymmetry
VIII
no vertigo and hearing loss
IX, X (+) gag reflex
XI
good shoulder shrug
XII
tongue in midline.

AT THE EMERGENCY ROOM

VITAL SIGNS
BP= 110/70 mmHg
HR= 108 bpm
RR= 26 cpm
T= 37.5C

AT THE EMERGENCY ROOM

(+) swelling of
the cheeks
(+) swelling of
the neck

AT THE EMERGENCY ROOM

November 9, 2014
8:00pm: Chest X-ray PA, 12LECG
8:45pm: Cervical AP/L
9:30pm: Advised admission
10:30pm: Relatives opted to bring the patient home due
to unavailability of room. Relatives will bring back the
patient once with available room.
Home Meds:
1. Levodropropizine (Levopront) 30mg/5mL syrup,
10cc TID
2. Metoprolol 100mg/tab OD

AT THE EMERGENCY ROOM

AT THE EMERGENCY ROOM

AT THE EMERGENCY ROOM

Chest X-ray PA
Suspicious densities in both upper lungs in which apical
series is suggested for further evaluation
Short curvilinear lucencies are now seen outlining both
cardiac borders suggestive of pneumomediastinum
Interval appearance of extensive subcutaneous
emphysema in both supraclavicular and axillary areas as
well as in both lateral chest walls
CT ratio is 0.56

AT THE EMERGENCY ROOM

Cervical AP/L
There is extensive subcutaneous emphysema in the
submental, anterior, posterior and lateral neck regions
and prevertebral soft tissues with widening of the
prevertebral soft tissue space

AT THE EMERGENCY ROOM

Sinus Tachycardia

SALIENT FEATURES
4 weeks history of
productive cough with
yellowish phlegm

Swelling of
cheeks and
neck area

45/F
Crepitus on the cheeks,
neck, supraclavicular area
and bilateral lung fields

High grade
fever =
39.0C

PRIMARY IMPRESSION
Pneumomediastinum with Subcutaneous Emphysema
secondary to Alveolar Rupture secondary to Presumptive
Pulmonary Tuberculosis
T/C Systemic Lupus Erythematosus

BASIS
Suspicious densities in
both upper lungs
Short curvilinear
lucencies suggestive of
pneumomediastinum
Extensive subcutaneous
emphysema in
supraclavicular, axillary
areas and in both lateral
chest walls
Extensive subcutaneous
emphysema in the
submental, anterior,
posterior and lateral
neck regions

XRAY FINDINGS

(+) crepitus on
the cheeks, neck,
supraclavicular
area and bilateral
lung fields
(+) tenderness
on the anterior
chest wall
(+) basal
crackles on the
right lung

P.E. FINDINGS

HISTORY

(+) cough with a

duration of 4 weeks
(+) on and off highgrade fever
(+) swelling of the
neck
(+) swelling of the
cheeks
(+) rashes on the
cheeks
(+) joint pain

DIFFERENTIAL DIAGNOSIS

COMMUNITY ACQUIRED PNEUMONIA

RULE IN
(+) productive cough with yellowish
sputum
(+) fever = 39.0C
(+) tachycardia
(+) tachypnea
(+) basal crackles, right lung field
(+) hazy infiltrates on lower lung
fields on CXR

RULE OUT
Cannot totally be ruled out

CHRONIC BRONCHITIS
RULE IN
(+) productive cough with yellowish
sputum
(+) dyspnea not usually
observed unless patient has COPD
or another condition that impairs
lung function

RULE OUT
(+) fever = 39.0C fever is
relatively unusual in Bronchitis
(-) use of accessory muscles
(-) radiologic findings

BRONCHIAL ASTHMA
RULE IN
(+) cough
(+) dyspnea

RULE OUT
(+) yellowish sputum
Cough occurs at any time of the
day In asthma, cough is usually
worse at night and patients typically
awake in the early morning hours
(-) wheezes
(-) rhonchi

BRONCHIECTASIS
RULE IN
(+) chronic productive cough with
yellowish sputum
(+) dyspnea
(+) weight loss
(+) basal crackles, right lung field

RULE OUT

(-) wheezes
(-) hemoptysis
(-) easy fatigability
(-) clubbing of the digits
(-) tram tracks on CXR

LUNG CARCINOMA
RULE IN

(+) chronic cough

(+) dyspnea
(+) weakness
(+) loss of appetite
(+) weight loss

RULE OUT
(-) hemoptysis
(-) radiologic findings

COURSE IN THE WARDS

CLINICAL COURSE: DAY 0 (11/10/14)

SUBJECTIVE

1.
2.
3.
4.

Productive cough
Dyspnea
Fever of 37.8C
Difficulty of breathing

OBJECTIVE

Pertinent PE: 100/80, 89, 30, 37.9C

Concsious, coherent, oriented to 3 spheres, (+) pallor (-) jaundice,
(+) subcutaneous emphysema, no use of accessory muscles while
breathing, (+) crackles on both lung field , symmetrical chest
expansion

ASSESSMENT

Pneumomediastinum with Subcutaneous Emphysema secondary to

Alveolar Rupture secondary to Presumptive PTB; T/C Systemic
Lupus Erythematosus

PLAN

1.
2.
3.
4.

IVF: PNSS 1L x 12 h
Blood work up: CBC, Na, K, BUN, Crea
Diagnostic: 12LECG, CXRAY PA, Sputum GS/CS, AFB x 2
Therapeutics: Levofloxacin 500 mg IV OD, Metoprolol
100mg/tab OD, Levopront 10ml TID, Cefipime 1gm IV Q8
()ANST, Vit B complex OD, Paracetamol 500 mg/ tab,
Paracetamol 300mg IV
5. O2 Support via nasal cannula at 2-3 lpm
6. WOF: chest pain, dyspnea, desaturation

CLINICAL COURSE: DAY 1 (11/11/14)

SUBJECTIVE

1. Productive Cough

OBJECTIVE

BP 120/80, 94, 18, 36.7, 95%

(+) pallor (-) jaundice, (+)
subcutaneous emphysema, (+)
crackles on R>L lung Field
Decreased hemoglobin level (85)

ASSESSMENT

Pneumomediastinum with
Subcutaneous Emphysema secondary
to Alveolar Rupture secondary to
Presumptive PTB; T/C Systemic
Lupus Erythematosus

PLAN

1. IVF: PNSS 1Lx 12h

2. For blood transfusion 2 pRBC
properly type and crossmatched
3. D/c Cefipime and shift to cefixime
200mg/cap BID
4. For repeat CXRAY PA, CBC

CLINICAL COURSE: DAY 2 (11/12/14)

SUBJECTIVE

1. Productive cough
2. Fever

OBJECTIVE

120/80, 118, 21, 38.4

(-) pallor (-) jaundice, (+) crackles on all
lung fields, (+) subcutaneous emphysema

ASSESSMENT

Pneumomediastinum with Subcutaneous

Emphysema secondary to Alveolar Rupture
secondary to PTB; T/C Systemic Lupus
Erythematosus

PLAN

1. IVF: PNSS 1L x 24h

2. Blood exam: FBS, HbA1C
3. Diagnostic: AFB Sputum x2, repeat
CXRAY
4. ROM: Metoprolol 100mg/tab OD,
Levopront 10ml TID, Cefixime 200mg
BID, Vit B complex OD, Paracetamol
500 mg/ tab, Paracetamol 300mg IV
5. Therapeutics: Start Quadtab 4 tabs OD
1 hour before breakfast

CLINICAL COURSE: DAY 4 (11/13/14)

SUBJECTIVE

1. Productive cough
2. Fever
3. Subcutaneous emphysema

OBJECTIVE

130/80, 104, 21, 37.9

(+) subcutaneous emphysema. (+)
crackles on right lung field

ASSESSMENT

Pneumomediastinum with
Subcutaneous Emphysema secondary
to Alveolar Rupture secondary to PTB;
T/C Systemic Lupus Erythematosus

PLAN

1.
2.
3.
4.
5.

Blood Exam: For Repeat CBC

Diagnostic: For chest CT Scan
Continue present antibiotics
Start Silgram 1.5gm IV
For gastro referral for co
management

CLINICAL COURSE: DAY 5 (11/14/14)

SUBJECTIVE

1. Productive cough
2. Dyspnea

OBJECTIVE

120/70, 98, 30, 37.4C

No intercostal retractions, (+) crackles
on right lung field

ASSESSMENT

CAP, MR; Pneumomediastinum with

Subcutaneous Emphysema secondary
to Alveolar Rupture secondary to PTB;
T/C Systemic Lupus Erythematosus

PLAN

1. IVF: PNSS 1L x 24hours

2. Continue present medications
3. Maintain nasal cannula at 3-4 lpm
while eating
4. Start Azithromycin 500mg/tab OD

CLINICAL COURSE: DAY 6 (11/15/14)

SUBJECTIVE

1. Productive cough
2. Fever

OBJECTIVE

110/70, 108, 33, 38.4C

No intercostal retractions, (+) crackles
on right lung field

ASSESSMENT

CAP, MR; Pneumomediastinum with

Subcutaneous Emphysema secondary
to Alveolar Rupture secondary to PTB;
T/C Systemic Lupus Erythematosus

PLAN

1. IVF: D5NSS 1L x 24h

2. Diet: NPO
3. Esophagogram with water stable
contrast done
4. For repeat CBC
5. Continue present antibiotics

CLINICAL COURSE: DAY 7 (11/16/14)

SUBJECTIVE

1. Cough
2. Fever
3. Difficulty of breathing

OBJECTIVE

140/70, 130, 40, 37.9, 82%

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema sec. to
Alveolar Rupture sec. to PTB; T/C
Systemic Lupus Erythematosus

PLAN

1. Patient was intubated

2. Hooked to MV: AC Mode, FiO2
100%80%, BUR 20, TV
350300
3. Shifted Silgram to Piperacillin
Tazobactam 45 mg IV Q6 ()ANST
4. Trasferred to MICU

CLINICAL COURSE: DAY 8 (11/17/14)

SUBJECTIVE

1. Fever
2. Cough

OBJECTIVE

130/80, 128, 24, 38.1, 98%

(+) bilateral crackles

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema sec. to
Alveolar Rupture sec. to PTB; T/C
Systemic Lupus Erythematosus

PLAN

1. Continue present medications

2. Decreased FiO2 to 70%
3. Start Vancomycin 1gm IV Q12
()ANST

CLINICAL COURSE: DAY 9 (11/18/14)

SUBJECTIVE

1. Fever
2. Difficulty of breathing

OBJECTIVE

140/80, 110, 30, 38.7, 93%

Bilateral crackles R>L

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema sec. to
Alveolar Rupture sec. to PTB; T/C
Systemic Lupus Erythematosus

PLAN

1.
2.
3.
4.
5.
6.

IVF: PNSS 1Lx 24

ABG and CBG done
Continue present medications
Given Furosemide 40mg IV
For Urinalysis and repeat CBC
Seen by Infectious medicine: For
repeat Blood CS x2, repeat chest
xray, ANA titer & ESR
7. Shifted PipTaz to Meropenem 1gm
(IV) Q8

CLINICAL COURSE: DAY 10 (11/19/14)

SUBJECTIVE

1. Fever
2. Productive cough
3. Difficulty of breathing

OBJECTIVE

100/70, 112, 30, 37.9, 90%

(+) bilateral crackles R>L

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema sec. to
Alveolar Rupture sec. to PTB; T/C
Systemic Lupus Erythematosus

PLAN

1. IVF: PNSS 1Lx 8h

2. Decrease FiO2 by 10% Q4 to
reach 40%, BUR 26
3. Discontinued Vancomycin
4. Continue present medications

CLINICAL COURSE: DAY 11 (11/20/14)

SUBJECTIVE

1. Productive cough
2. Fever
3. Difficulty of breathing

OBJECTIVE

130/70, 120, 40, 39.8, 88%

(+) crackles and wheezes on both lung
fields

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema, resolving;
Clinically-diagnosed PTB; T/C
Systemic Lupus Erythematosus

PLAN

1.
2.
3.
4.

IVF: PNSS 1Lx 8h

Metoprolol was held
Start giving Coralan 5mg /tab BID
Nebulization done by giving USN
w/ Duavent Q8
5. FiO2 resumed to 70%
6. Continue present medications:
7. For transfusion of 1 pRBC

CLINICAL COURSE: DAY 12 (11/21/14)

SUBJECTIVE

1. Fever
2. Productive cough
3. Difficulty of breathing

OBJECTIVE

140/100, 154, 40, 38.7C, 89-90% (+)

crackles on left lung field

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema, resolving;
Clinically-diagnosed PTB; T/C
Systemic Lupus Erythematosus

PLAN

1.
2.
3.
4.

IVF: PNSS 1L x 12
For 12LECG
Furosemide 40mg was given
Verapamil 2.5mg syrup 1 dose
given
5. FiO2 from 80% to 100%
6. Nebulized with Duavent x2 doses
7. For repeat Na,K, Crea

CLINICAL COURSE: DAY 13 (11/22/14)

SUBJECTIVE

1. Fever
2. Productive cough
3. Difficulty of breathing

OBJECTIVE

130/80, 135, 32, 37.8C, 94% (+)

crackles on left lung field
Hgb: 87

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema, resolving;
Clinically-diagnosed PTB; T/C
Systemic Lupus Erythematosus

PLAN

1. IVF: PNSS 1L x 12
2. For blood transfusion of 1 unit
pRBC once available
3. Give Furosemide 40mg IV
4. Decrease FiO2 to 90%

CLINICAL COURSE: DAY 14 (11/23/14)

SUBJECTIVE

1. Fever
2. Productive cough
3. Difficulty of breathing

OBJECTIVE

120/80, 130, 36, 38.3C, 90%

(+)crackles on Left lung field

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema, resolving;
Clinically-diagnosed PTB; T/C
Systemic Lupus Erythematosus

PLAN

1. IVF: PNSS 1L x 16
2. Given Furosemide 2g IV
3. Decrease PEEP to12

CLINICAL COURSE: DAY 15 (11/24/14)

SUBJECTIVE

1. Fever
2. Productive cough
3. Difficulty of breathing

OBJECTIVE

130/8080/60, 180, 40, 37.8C, 93%

(+)crackles on Left lung field
ANA Test Positive

ASSESSMENT

Acute Respiratory Failure Type 2 sec. to

CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema, resolving;
Clinically-diagnosed PTB; Systemic Lupus
Erythematosus

PLAN

1. Start Norepinephrine 8cc + Q2 PNSS via

solulet x 10ugtts/min x 2 cycle
2. Increase BUR to 28
3. Diazepam 2.5mg IV
4. Cardiovert 100 joule was done
5. Start Hydrocortisone 100mg IV Q8
6. Amiodarone 150mg
7. Amiodarone Drip 300mg +D5W 250ccx 24 h
8. For Rheuma referral
9. 1st dose of Epinephrine was given
10. Decrease Norepi 5 ugtts/min

CLINICAL COURSE: DAY 16 (11/25/14)

SUBJECTIVE

1. Productive cough
2. Difficulty of breathing

OBJECTIVE

80/60, 130-140s, 36, 38.3C, 90%

(+)crackles on Left lung field
(-) corneal; pupil 4mm dilated

ASSESSMENT

Acute Respiratory Failure Type 2 sec.

to CAP, HR; Pneumomediastinum with
Subcutaneous Emphysema, resolving;
Clinically-diagnosed PTB; T/C
Systemic Lupus Erythematosus

PLAN

1. Increase Norepinephrine
20ugtts/min
2. Decrease PEEp to 8
3. For ABG
4. For Na,K,
5. NaCHo3 SIVP was given

FINAL DIAGNOSIS
Acute Respiratory Failure Type II secondary to
Community-Acquried Pneumonia, High Risk
Pneumomediastinum with Subcutaneous Emphysema,
resolving
Clinically-diagnosed Pulmonary Tuberculosis
Systemic Lupus Erythematosus

CASE DISCUSSION

ACUTE RESPIRATORY FAILURE

A condition in which the respiratory system fails in one or
both of its gas exchanging functions
Oxygenation
CO2 elimination

TYPES OF RESPIRATORY FAILURE

TYPES

DEFINITION

Type I

acute hypoxemic respiratory failure

(generally PO2 <55-60mmHg)
May occur due to alveolar flooding
and subsequent intrapulmonary
shunting

Type II

Hypercarbic respiratory failure

(generally pCO2 >45-50mmHg)
May result from alveolar
hypoventilation and subsequent
hypercarbia

Type III

Occurs as a result of lung

atelectasis

Type IV

Results from hypoperfusion of

respiratory muscles in patients in
shock

SYSTEMIC LUPUS ERYTHEMATOSUS

Basic Pathophysiology
Autoimmune disease where organs and cells undergo
damage mediated by tissue-binding autoantibodies and
immune complexes
Diagnosis and Clinical Manifestations

Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood/Hematologic disorder
Renal disorder
ANA (+)
Immunologic disorder
Neurologic disorder
Malar rash
Discoid rash

MANAGEMENT OF SLE
Analgesics and antimalarials are the mainstays of
treatment for mild disease
Systemic steroids are the mainstays of severe disease

PNEUMOMEDIASTINUM;
SUBCUTANEOUS
EMPHYSEMA

OVERVIEW
Subcutaneous emphysema is characterized by painless
swelling of the tissues because of air tracking along
tissue planes. It is commonly seen over the chest wall
around drain sites, in the head and neck.
Palpation elicits a characteristic tissue paper feeling
beneath the fingers. Air may track deeper into the
mediastinum, retroperitoneum, scrotum, and down into
the limbs.

OVERVIEW
In pneumomediastinum, there is gas in the interstices of
the mediastinum. Typically, there is severe substernal
chest pain with or without radiation into the neck and
arms.
The diagnosis is confirmed with the chest radiograph.
Usually no treatment is required, but the mediastinal air
will be absorbed faster if the patient inspires high
concentrations of oxygen. If mediastinal structures are
compressed, the compression can be relieved with
needle aspiration.

PATHOPHYSIOLOGY
The three main causes are:
1. Alveolar rupture with dissection of air into the
mediastinum
2. Perforation or rupture of the esophagus, trachea, or
main bronchi
3. Dissection of air from the neck or the abdomen into
the mediastinum.

CAUSES
Forceful coughing, crying, or shouting may elevate
pressures. Vomiting, defecation, and Valsalva maneuver
may elevate pulmonary alveolar pressures, as may illicit
drug use, especially if associated with coughing.
Strenuous athletic activity, diving, flying, playing musical
instruments, and childbirth are also potential risk factors.

CAUSES
Obstructive lung disease (eg, asthma, bronchiolitis,
foreign body aspiration, bronchopulmonary dysplasia),
especially in intubated and mechanically ventilated
patients, is a risk factor.
Respiratory tract infections, especially if associated with
asthma, may predispose a patient to the development of
a pneumomediastinum.

SIGNS AND SYMPTOMS

The most common symptoms seen with
pneumomediastinum were subcutaneous emphysema
(76% of patients) and neck or chest pain (38% of
patients).
In spontaneous pneumomediastinum, pain is said to be
a feature in 50-90% of cases. Typically, it is retrosternal
in location and worsened by inspiratory maneuvers. The
pain may radiate to the shoulders or back.

SIGNS AND SYMPTOMS

Dyspnea may reflect associated illnesses such as
asthma, a coexistent pneumothorax, or a tension
pneumomediastinum.
Low-grade fever may be present. Fever may occur
following cytokine release that is associated with air leak.
However, mediastinitis or infectious/inflammatory
disorders should be included in the differential diagnosis
when fever is present.

SIGNS AND SYMPTOMS

Patients may present with symptoms of throat pain. Jaw
pain has occasionally been reported. Dysphagia, neck
swelling, and torticollis all have been reported in
association with spontaneous pneumomediastinum.

MANAGEMENT
Diagnostic
Chest radiography usually reveals a
pneumomediastinum. Chest radiography reveals air
within the mediastinal space. Coexisting disease (eg,
pneumothorax, pneumoperitoneum,
pneumoretroperitoneum of pneumopericardium) may
also be evident.

MANAGEMENT
Radiolucent streaks representing free air may be
observed tracking along the margins of the heart, within
the retrosternal space, or surrounding the trachea.
Typical features of pneumomediastinum seen on chest
radiography are caused by air outlining normal anatomic
structures as it tracks from the mediastinum producing
the thymic sail sign, "ring around the artery" sign, tubular
artery sign, double bronchial wall sign, continuous
diaphragm sign, and the extrapleural sign.

MANAGEMENT
Therapeutic
The tissues in the mediastinum will slowly resorb the air
in the cavity so most pneumomediastinums are treated
conservatively. Breathing high flow oxygen will increase
the absorption of the air.
If the air is under pressure and compressing the heart, a
needle may be inserted into the cavity, releasing the air.
Surgery may be needed to repair the hole in the trachea,
esophagus or bowel.

MANAGEMENT
If there is lung collapse, it is imperative the affected
individual lies on the side of the collapse, although
painful, this allows full inflation of the unaffected lung.

REFERENCES
Longo, D., Fauci, A., et.al., 2012. Harrisons Principles of
Internal Medicine, 18th edition, McGraw-Hill Companies,
Inc., USA
http://www.emedicine.medscape.com
http://
www.nlm.nih.gov/medlineplus/ency/article/003286.htm

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