What is the treatment for pneumopericardium?

Treatment for Pneumopericardium

The treatment for pneumopericardium depends on hemodynamic stability, with immediate pericardiocentesis or pericardial drainage indicated for tension pneumopericardium causing cardiac tamponade. 1

Assessment and Diagnosis

• Pneumopericardium is defined as the presence of air in the pericardial sac, which can be diagnosed through chest CT scan or chest radiography 2, 1
• Clinical presentation may include signs of cardiac tamponade such as hypotension, muffled heart sounds, and hemodynamic instability when sufficient air accumulates 2
• Tension pneumopericardium occurs in approximately 37% of pneumopericardium cases and represents a life-threatening emergency 3

Treatment Algorithm

For Hemodynamically Stable Pneumopericardium:

• Close monitoring of vital signs and electrocardiography at an intermediate care unit 1
• Observation is appropriate as most cases are self-limiting and require no specific therapy 1, 4
• When pneumopericardium is associated with pneumothorax, chest tube drainage of the pneumothorax is often sufficient 4
• Identify and treat the underlying cause (e.g., trauma, positive pressure ventilation) 2, 5

For Tension Pneumopericardium/Cardiac Tamponade:

• Immediate pericardiocentesis (needle aspiration) to relieve pressure 1, 3
• Following initial decompression, placement of a pericardial drainage tube for continued drainage 2, 3
• Surgical options include:
  • Pericardial window creation 1
  • Emergent open subxyphoid approach to the pericardium 1
  • Pericardiectomy in selected cases 6

For Specific Etiologies:

• For traumatic pneumopericardium:

  • Exclude tracheobronchial or esophageal tears through bronchoscopy or esophagogastroduodenoscopy 1
  • Surgical repair of identified injuries to vital structures 4

• For neoplastic involvement with pneumopericardium:

  • Extended pericardial drainage 6
  • Consider intrapericardial instillation of cytostatic/sclerosing agents if associated with malignant effusion 6

Special Considerations

• Mortality associated with pneumopericardium is high (57% overall), even in cases without tension (58%), often due to underlying conditions 3
• In neonates with pneumopericardium secondary to positive pressure ventilation, prompt recognition and treatment are critical 5
• For recurrent pneumopericardium, options include:
  • Balloon pericardiotomy creating a pleuropericardial window 6
  • Surgical pericardial window via thoracotomy 6
  • Video-assisted thoracoscopic window creation 6

Monitoring and Follow-up

• Continuous cardiac monitoring is essential during treatment 1
• Serial imaging (echocardiography or CT) to confirm resolution 2
• Address underlying causes to prevent recurrence 2, 1