From the Research
Management of adult pneumomediastinum primarily involves supportive care and treating the underlying cause, with most cases resolving spontaneously within 7-10 days with conservative management, and hospitalization is not always necessary, as shown in a study from 1. The goal of treatment is to alleviate symptoms, prevent complications, and allow the body to absorb the air in the mediastinum.
- Patients should be placed on bed rest, given supplemental oxygen as needed to maintain oxygen saturation above 92%, and provided with adequate pain control using acetaminophen or NSAIDs.
- Avoid medications that may suppress cough reflexes.
- Antibiotics are not routinely indicated unless there is evidence of infection or if the pneumomediastinum resulted from esophageal perforation, in which case broad-spectrum antibiotics covering oral flora should be initiated, as suggested by 2.
- For severe cases or those with significant respiratory distress, hospital admission for observation is recommended.
- Patients should avoid activities that increase intrathoracic pressure, such as Valsalva maneuvers, strenuous exercise, and smoking.
- Follow-up imaging with chest X-ray is typically performed after 24-48 hours to ensure improvement. The most recent and highest quality study, 3, provides a comprehensive review of the epidemiology, etiology, and pathophysiology of pneumomediastinum, and supports the approach of conservative management for most cases. It's worth noting that, a study from 4, recommends a new algorithm for management of spontaneous pneumomediastinum based on clinical experience, which includes shortened hospitalization for about 2 days with observation alone, if the symptoms improve gradually. However, the study from 5, although focused on pneumomediastinum and pneumothorax in acute respiratory distress syndrome (ARDS) patients, highlights the importance of lung-protective ventilation strategies in reducing the occurrence of barotrauma, such as pneumomediastinum. Overall, the management approach should prioritize supportive care, treating the underlying cause, and preventing complications, with hospitalization reserved for severe cases or those with significant respiratory distress, as supported by the highest quality and most recent evidence from 1 and 3.