Initial Management of Pneumomediastinum
For spontaneous pneumomediastinum in stable patients, conservative management with observation and supportive care is the appropriate initial approach, as this is a benign, self-limited condition that does not require extensive invasive workup or intervention. 1
Immediate Assessment and Risk Stratification
The first priority is distinguishing spontaneous pneumomediastinum from life-threatening causes requiring urgent intervention:
- Obtain chest CT scan immediately to confirm pneumomediastinum and assess for associated injuries, as CT has 100% sensitivity for detecting the condition and identifying high-risk features 2
- Evaluate for signs of esophageal perforation or major airway injury, which are uncommon but require different management 2, 1
- Key differentiating features suggesting benign spontaneous pneumomediastinum include: younger age (typically teens to 20s), normal or minimally elevated white blood cell count, and absence of pleural effusion 1
Conservative Management Protocol (For Stable Patients)
Most patients with uncomplicated spontaneous pneumomediastinum respond well to oxygen and conservative management without specific treatment 3:
- Provide supplemental oxygen and rest to facilitate air resorption 4, 3
- Monitor with serial chest radiographs to assess resolution 5, 3
- Close cardiopulmonary monitoring for potential complications, including vital signs, respiratory rate, heart rate, blood pressure, and oxygen saturation 5, 3
- Hospitalize for observation (mean duration 1.8 days) with expectation of symptom resolution within 5-7 days 3, 1
The mediastinal tissues will slowly resorb the air, making invasive interventions unnecessary in most cases 4.
When to Pursue Additional Workup
Esophagography and bronchoscopy should be performed selectively, not routinely 1:
- CT findings suspicious for major injury (present in only 20% of pneumomediastinum cases) warrant endoscopic evaluation 2
- Clinical red flags including: older age, elevated white blood cell count, pleural effusion, or signs of sepsis suggest possible esophageal perforation requiring contrast esophagography 1
- In blunt trauma patients, CT scan alone is sufficient screening; only those with suspicious CT findings require bronchoscopy or esophagography 2
A study of 81 patients managed with observation alone (no endoscopic evaluation) showed no delayed diagnoses, missed injuries, or complications 2.
Special Circumstances Requiring Intervention
Tension Pneumomediastinum (Rare but Critical)
If tension pneumomediastinum develops with hemodynamic compromise, immediate decompression is required 6:
- Insert chest drains for decompression in unstable patients 6
- Recognize cardiac tamponade physiology from increased intrathoracic pressure on venous return 4, 6
- This complication occurs primarily in mechanically ventilated patients with ARDS, not spontaneous cases 6
Ventilated Patients with Suspected Bronchopleural Fistula
Insert a large-bore chest tube (24F-28F) connected to water seal with suction 5
Common Pitfalls to Avoid
- Do not perform routine esophagography on all pneumomediastinum patients—this was done in 35% of one series and was invariably negative in spontaneous cases 1
- Do not confuse with pneumothorax management—pneumomediastinum does not require chest tube placement unless tension physiology develops 4, 3
- Do not discharge prematurely—observation for 24-48 hours is prudent even in asymptomatic patients 3, 1
- Recognize Hamman's crunch on auscultation (crunching sound with cardiac cycle) as a diagnostic clue 4