How do you manage worsening pneumomediastinum from excessive coughing as an asthma attack?

Management of Worsening Pneumomediastinum from Excessive Coughing During an Asthma Attack

The management of worsening pneumomediastinum from excessive coughing during an asthma attack should focus on aggressive treatment of the underlying asthma exacerbation while providing supportive care, as pneumomediastinum is typically self-limiting and resolves with conservative management. 1, 2, 3

Initial Assessment and Management

Primary Treatment

• Administer high-flow oxygen (40-60%) to maintain SpO2 >90% (>95% in pregnant women and patients with heart disease) 4
• Provide inhaled short-acting β2-agonists:
  • Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 4
  • Repeat every 20-30 minutes for the first hour, then as needed based on response 4
• Administer systemic corticosteroids:
  • Oral prednisolone 30-60 mg or
  • IV hydrocortisone 200 mg if unable to take oral medication 4
• Consider adding ipratropium bromide 0.5 mg to nebulizer treatment, especially in severe cases 4

Specific Considerations for Pneumomediastinum

• Obtain chest radiograph to confirm pneumomediastinum and rule out complications such as pneumothorax 4, 3
• Consider CT scan if chest X-ray is inconclusive 3
• Avoid positive pressure ventilation if possible, as it may worsen air leakage 1
• Provide adequate analgesia for chest pain 3
• Avoid maneuvers that increase intrathoracic pressure (Valsalva, forceful coughing) 5

Ongoing Management

Asthma Control

• Continue oxygen therapy to maintain adequate saturation 4
• Continue bronchodilator therapy with inhaled β2-agonists at appropriate intervals based on severity 4
• Complete a course of systemic corticosteroids (typically 3-10 days) 4
• Monitor response to treatment through clinical assessment and, when appropriate, pulmonary function tests 4

Pneumomediastinum Monitoring

• Serial chest radiographs to monitor resolution of pneumomediastinum 2, 3
• Monitor for rare complications such as tension pneumomediastinum or progression to pneumothorax 5
• Observe for signs of respiratory distress that may indicate worsening of condition 1

Indications for More Aggressive Intervention

• Significant respiratory distress despite optimal asthma management 3
• Evidence of tension pneumomediastinum causing compression of vital structures 3
• Development of pneumothorax 5
• Hemodynamic instability 1

Discharge Criteria and Follow-up

• Resolution or significant improvement of asthma symptoms 4
• FEV1 or PEF ≥70% of predicted value or personal best 4
• Stable or improving pneumomediastinum on imaging 2
• Patient education on:
  • Asthma action plan 4
  • Proper inhaler technique 4
  • Recognition of worsening symptoms 4
• Arrange follow-up within 1 week 4
• Consider referral to pulmonologist for long-term management 4

Common Pitfalls to Avoid

• Underestimating the severity of the asthma exacerbation 4
• Delaying corticosteroid administration 4
• Unnecessary invasive interventions for uncomplicated pneumomediastinum 1, 2, 3
• Failure to monitor for rare but serious complications 5
• Discharging patients too early before adequate resolution of both asthma and pneumomediastinum 2

Most cases of pneumomediastinum secondary to asthma resolve spontaneously with conservative management focused on treating the underlying asthma exacerbation 1, 2, 5. Surgical intervention is rarely required and typically only necessary in cases of tracheobronchial compression 3.