Chest Pain in the Emergency Department

Chest x-ray showed hypotransparency of the paracardiac mediastinum with a discrete air lamina involving the cardiac silhouette. Computed tomography scan revealed a pneumomediastinum affecting all compartments and extending to the cervical region with coexisting emphysema of the superior thoracic wall.
Pneumomediastinum results from the dissociation of the air of the pulmonary parenchyma within the mediastinum. It is commonly a self-limited process, without the need for aggressive intervention and occurs mainly in male adolescents. The most frequent symptom is chest pain – which our adolescent reported.¹ The most common causes are asthma exacerbations, bronchospasm, cough, respiratory tract infection, and vomiting. These are activities that require the Valsalva maneuver.² On further enquiry in our patient, it was found that the adolescent had been taught some respiratory exercises, which she did daily at home. After being questioned she recalled her symptoms has begun the day before after she had done her respiratory exercises due to severe school-related anxiety.
The diagnosis is confirmed by a chest x-ray, although it may be helpful to perform a CT-scan in order to better characterize the clinical condition as well as detect possible complications.³ The treatment is conservative and essentially symptomatic¹; however, it is necessary to exclude and underlying pulmonary conditions. Prognosis is favorable in most cases.

References :

Chen I-C, Tseng C-M, Hsu J-H, Wu J-R, Dai Z-K. Spontaneous pneumomediastinum in adolescents and children. Kaohsiung J Med Sci. 2010;26:84–8. Gasser CR-B, Pellaton R, Rochat CP. Pediatric Spontaneous Pneumomediastinum: Narrative Literature Review. Pediatr Emerg Care. 2017;33:370–4. Kouritas VK, Papagiannopoulos K, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, et al. Pneumomediastinum. J Thorac Dis. 2015;7(Suppl 1):S44-9.