Management of Pneumomediastinum
Pneumomediastinum in clinically stable patients should be managed conservatively with outpatient observation, rest, analgesia, and treatment of the underlying cause (most commonly asthma), as it typically resolves spontaneously within several days without requiring invasive intervention. 1, 2
Initial Assessment and Risk Stratification
Determine clinical stability by evaluating:
- Respiratory rate (<24 breaths/min indicates stability) 3
- Heart rate (60-120 beats/min) 3
- Oxygen saturation (>90% on room air) 3
- Ability to speak in complete sentences between breaths 3
- Presence or absence of respiratory distress 4
Identify the underlying cause, as this drives management:
- Asthma is the most common cause in children and young adults 1, 5, 2
- Rule out esophageal perforation if there is any clinical suspicion (requires contrast esophagogram) 1, 2
- Consider trauma, infection, or structural airway abnormalities in atypical presentations 4
Diagnostic Approach
Confirm diagnosis with chest radiography as the initial imaging modality, which is usually sufficient 1, 5, 2
Obtain CT chest without IV contrast only if:
- Chest radiograph is equivocal 6
- You need to evaluate for underlying structural causes (such as tracheobronchial injury) 6, 4
- Patient cannot reliably follow up or any delay could be life-threatening 6
Perform contrast esophagogram if there is any suspicion of esophageal perforation, as this is the critical differential diagnosis that changes management entirely 1, 2
Management Algorithm Based on Clinical Stability
For Clinically Stable Patients (The Majority)
Manage conservatively with outpatient treatment consisting of:
- Rest and activity restriction 1, 2
- Analgesics for chest pain 1, 5, 2
- Oxygen supplementation if needed 5
- Treatment of underlying asthma or other precipitating condition 1, 5
- Clinical monitoring with follow-up within 12 hours to 2 days 3
Avoid invasive procedures such as chest tube placement, as pneumomediastinum typically resolves spontaneously within several days 1, 2
For Clinically Unstable Patients or Those with Respiratory Distress
Hospitalize immediately and consider:
- Continuous monitoring with pulse oximetry 7
- Aggressive treatment of underlying cause (particularly asthma exacerbation) 5, 8
- Surgical intervention only if tracheobronchial compression develops 5, 4
Tension pneumomediastinum (extremely rare) requires immediate decompression, similar to tension pneumothorax management 2
Special Considerations for Asthma-Related Pneumomediastinum
Recognize that pneumomediastinum complicates asthma exacerbations and may coexist with pneumothorax 6, 5, 8
Screen for pneumothorax with chest radiography, as this is the more concerning complication requiring different management (pneumothorax occurs in 0.5-2.5% of status asthmaticus admissions and was the direct cause of death in 27% of acute exacerbation fatalities in one series) 6
If BiPAP is being used chronically, consider discontinuation during the acute episode if pneumothorax is also present 6
Critical Pitfalls to Avoid
Do not reflexively perform invasive procedures (chest tube placement, mediastinoscopy) for stable pneumomediastinum, as observation is safer and avoids unnecessary pain and complications 3, 1
Do not miss esophageal perforation, which requires urgent surgical intervention rather than conservative management—obtain contrast esophagogram if there is any doubt 1, 2
Do not discharge patients without reliable follow-up, especially those living far from emergency services 3
Perform pulmonary function testing after resolution in cases of idiopathic pneumomediastinum to establish whether underlying asthma is present 1
Follow-Up and Prevention
Identify and control predisposing factors (particularly asthma triggers) to prevent recurrence 1
Obtain repeat imaging to confirm resolution if symptoms persist beyond expected timeframe (typically 8 days) 2
Ensure close clinical monitoring during the observation period, with repeat imaging to exclude progression 3