Disorders of the Mediastinum: Student/Resident Case Report Poster - Disorders of the Mediastinum |

Spontaneous Pneumomediastinum From Sustained Valsalva FREE TO VIEW

Aritra Sen, MD; Pratik Doshi, MD; Bela Patel, MD
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UT Health Science Center, Houston, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):550A. doi:10.1016/j.chest.2016.08.638
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SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: This case discusses the physiology of pneumomediastinum secondary to sustained valsalva and correct management.

CASE PRESENTATION: Twenty year old Hispanic male presented for one day history of nausea, fatigue and chest pain. The patient reports daily marijuana use for recreation. The day prior to admission, he smoked 11 grams which initiated several instances of nonbloody and nonbilious vomiting. He reported sharp and retrosternal chest pain not worsened with exertion. A few hours after being admitted, his chest pain and nausea had subsided. X-rays and CT scans showed air within the mediastinum as well as air in the subcutaneous chest wall. The patient did not require subsequent oxygen support or pain control. He was discharged the next day from the hospital with outpatient followup and extensive counseling on drug abuse.

DISCUSSION: Repeated Valsalva maneuvers are performed to increase the high during marijuana smoking. The elevated intrathoracic pressure leads to rupture of alveolar membrane causing positive pressure gradient of air from lungs into the mediastinum. In a retrospective study of 500 patients with mediastinal emphysema, 15 patients had repeated Valsalva maneuvers secondary to marijuana use. In all the cases, the patients recovered without further sequelae in two to five days. The differential diagnosis is broad and includes alveolar rupture, tracheobronchial injury, esophageal perforation, head/neck surgery and abdominal injury. Severe asthma, airway obstruction and rib fractures may lead to alveolar rupture. Iatrogenic injury and trauma to trachea, head, neck and abdomen often lead to tracking air down to the mediastinum, The most life threatening cause of pneumomediastinum is secondary to esophageal perforation. Tachycardia is the initial SIRS response within 24 to 48 hours. The Mackler's triad of vomiting, lower chest pain and subcutaneous emphysema may be present. Chest radiograph with water soluble material or a CT scan would be appropriate to identify perforation. Many patients need surgery as irrigation and debridement of mediastinum is required as well as closure of perforation. Percutaneous drainage is often a possibility if it perforation is in the neck and is easilly accessible.

CONCLUSIONS: Repeated sustained valsalva often results in pneumothorax and pneumomediastinum. All reported cases in the literature show safe observation for one to two days is adequate if esophageal perforation is not suspected. If esophgeal perforation occurs, tachycardia is often first symptom with SIRS response occuring within 24-48 hours. Emergent surgery and/or percutaneous drainage may be indicated if it is not a contained perforation.

Reference #1:Esophageal perforation and Acute Bacterial Mediastinitis: Other Causes of Chest Pain That Can be Easily Missed Cross et al. Medicine (Baltimore) 2015

Reference #2:Pneumomediastinum in heroin and marijuana users Mattox et al. Journal of the American College of Emergency Physicians 1976

DISCLOSURE: The following authors have nothing to disclose: Aritra Sen, Pratik Doshi, Bela Patel

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