Pneumomediastinum Treatment
The initial treatment for pneumomediastinum is conservative management with observation, rest, oxygen therapy, and analgesics, as this benign condition typically resolves spontaneously within 3-10 days without specific intervention. 1, 2
Initial Assessment and Diagnosis
When pneumomediastinum is suspected, the priority is to exclude life-threatening conditions that require emergency intervention:
- Rule out esophageal perforation using water-soluble contrast esophagography, as this is a surgical emergency requiring immediate intervention 3, 1
- Exclude necrotizing mediastinitis, which would necessitate urgent surgical debridement 1
- Chest radiography is diagnostic in most cases, showing mediastinal air, and may reveal associated findings like pneumothorax or subcutaneous emphysema 1, 4
- CT scan should be performed to confirm diagnosis, assess extent, and definitively exclude esophageal rupture or other serious pathology 3, 2, 5
Conservative Management Protocol
Once life-threatening causes are excluded, spontaneous pneumomediastinum responds excellently to conservative treatment alone 1, 2, 4:
- Bed rest to minimize further air dissection 1
- Oxygen therapy to promote nitrogen washout and accelerate air resorption 1, 2
- Analgesics for chest pain management, as retrosternal pain is the most common presenting symptom 1, 4
- Close cardiopulmonary monitoring for potential complications, though these are rare 2
Hospital Admission and Monitoring
- Admit for observation with typical hospital stays ranging 3-10 days 1
- Serial chest radiographs to monitor resolution 2
- Monitor for rare complications including tension pneumomediastinum or tension pneumothorax 4
- Patients should be discharged only when symptoms resolve and they tolerate oral fluids well 3
Specific Interventions (Rarely Needed)
Subcutaneous air drainage may be required in only approximately 13% of cases when massive subcutaneous emphysema causes significant discomfort, but this does not affect the pneumomediastinum itself 5
Surgical intervention is generally not needed for spontaneous pneumomediastinum 5
Important Clinical Pitfalls
- Do not confuse with pneumothorax management: Unlike pneumothorax, pneumomediastinum does not require chest tube drainage 3, 1
- The presence of subcutaneous emphysema occurs in only about 50% of cases, so its absence does not exclude pneumomediastinum 1
- Normal chest radiograph does not exclude the diagnosis if clinical suspicion is high; proceed to CT imaging 3
- Always provide written discharge instructions indicating patients must return immediately if they develop worsening pain, breathlessness, or fever 3