Mediastinal emphysema describes the accumulation of air in the mediastinum. The condition usually occurs in conjunction with mechanical ventilation. The main cause is alveolar overpressure, which can occur, for example, as a result of a Valsalva maneuver, cough disease, or blunt chest trauma.
What is mediastinal emphysema?
The mediastinum refers to a space located between the two lungs. Several vital organs, such as the heart and airways, are located here. These are surrounded by a supportive tissue called connective tissue. This ensures that the corresponding organs find stable support in the mediastinum. Mediastinal emphysema develops due to an overflow of air into the mediastinal area. This usually escapes from the so-called alveolar space. The function of the lungs is rarely affected. In most cases, the disease occurs in conjunction with pneumothorax or skin emphysema. Symptoms of its own occur rather rarely. The treating physician may notice a crackling sensation by palpating the jugular. If there is pronounced mediastinal emphysema, those affected often suffer from severe pericardial discomfort. In addition, pronounced mediastinal emphysema results in so-called influence congestion.
Causes
Basically, air leakage occurs in all perforations of air-filled organs. Most commonly, the bronchial area or the gastrointestinal tract are affected, from which air can enter the mediastiunum. The physician distinguishes spontaneous from non-spontaneous mediastinal emphysema. So-called spontaneous mediastinal emphysema occurs without prior trauma. Pulmonary disease is usually not underlying. Spontaneous mediastinal emphysema often follows an intrathoracic increase in pressure. It is thought to occur as a result of rupture of the alveoli, causing air to leak from the airways into the mediastinum. In most cases, pressure-increasing factors such as severe coughing, vomiting, straining, or asthma disease can be elicited. In addition, it is likely that the body’s inflammatory responses cause rupture of the peripheral alveoli in so-called bronchial asthma. Other possible causes include spontaneous pneumomediastinum, airway obstruction, the Valsalva maneuver, drug abuse, or invasive ventilation. There are many underlying causes of non-spontaneous pneumothorax. The leakage of air as a result of trauma to a hollow organ or tumor disease presents as life-threatening. Foreign bodies that have penetrated the lungs may also be the cause of mediastinal emphysema.
Symptoms, complaints, and signs
The organs, which are located in the chest cavity, are displaced by air. The individual complaints mainly depend on which organs have been affected by this process. In most cases, patients suffer from severe pain in the area of the heart or the sternum. If the trachea is constricted, breathing problems occur. If the esophagus is affected, patients complain of difficulty swallowing. If blood vessels or the heart are involved, the symptoms are not always clearly assignable. In this case, there is often palpitations and shortness of breath, which also suggests other diseases. Furthermore, it is possible that the escaped air penetrates into the skin. Characteristic of this so-called skin emphysema is the visible accumulation of air in the neck area and on the arms.
Diagnosis and course of the disease
The air that accumulates in the mediastinal space can often be perceived by the physician as a crackling sound. This is caused by the air bubbles that are located under the skin. A widened mediastinal space can be seen in the chest X-ray. An inconspicuous mediastinum is usually seen here as a narrow white area between the two lung lobes, which appear dark in the image. Air that has entered the mediastinal space makes this area appear wider. On the x-ray, this air-filled area can be seen as a dark section, as can the lungs. All organs that contain fluid show a lighter area on x-ray. This can also be recognized by the blood-filled heart, which forms the white area in the mediastinum.
Complications
Mediastinal emphysema can cause a variety of symptoms.As a rule, the complaints strongly depend on which organs are displaced in which direction and thereby possibly deformed and damaged. For this reason, a general course of the disease cannot be predicted. In most cases, however, there is discomfort and pain in the heart. It is not uncommon for those affected to suffer from feelings of anxiety or panic attacks. Pain occurs, which can spread to other regions of the body. It is not uncommon for mediastinal emphysema to be associated with breathing difficulties. Furthermore, swallowing difficulties also occur, so that the intake of food and liquid is usually no longer possible without further ado. The shortness of breath can also cause sufferers to lose consciousness and possibly injure themselves in the event of a fall. Without treatment of mediastinal emphysema, the patient may also die. In most cases, no direct treatment is necessary for mediastinal emphysema. Only in acute emergencies is surgical intervention performed, but this is not associated with complications. With successful treatment, the patient’s life expectancy is not reduced by mediastinal emphysema.
When should you see a doctor?
People who receive mechanical ventilation are increasingly in the risk group for mediastinal emphysema. Therefore, affected individuals in particular who are in the appropriate state of health should inform their attending physician if they notice any changes or abnormalities. Restrictions in breathing activity, unusual breathing sounds or severe chest pain are signs of possible disorders and existing problems. A physician should be informed immediately so that treatment can be optimized. Difficulty swallowing, rapid heartbeat, sweating, and anxiety are signs of existing irregularities. If there is an increase in existing symptoms or if symptoms continue to spread, a visit to the doctor should be made as soon as possible. If a visible accumulation of air can be perceived in the arms and neck of the affected person, a doctor is needed. If a lack of oxygen in the organism is noticed, if a pallor of the skin appears or if there is a blue discoloration, a doctor should be consulted. A decrease in physical resilience, fatigue, rapid fatigue and sleep disturbances are indications that must be examined and treated. If the physical symptoms are accompanied by mental stress, a doctor should also be consulted. In the case of depressive behavior, aggressive tendencies or severe mood swings, medical support may be helpful. Withdrawal from social life, tearfulness or apathy indicate psychological problems that should be addressed and clarified.
Treatment and therapy
Therapy for mediastinal emphysema is usually symptomatic only. In most cases, the air disappears on its own without treatment because it is absorbed by the surrounding tissue. In technical language, this process is called resorption. The pressure in the mediastinal area is rarely so high that the air must be removed. If this becomes necessary, an invasive procedure is required in which an incision is made in the patient’s neck. This then allows the air to escape. If mediastinal emphysema develops into a life-threatening condition, this surgery is performed. Basically, only the underlying conditions are treated. This includes, for example, closing a rupture or the use of ventilators. If patients are free of symptoms and discomfort, no further therapy is required. If the pain is severe, an incision cranial to the sternum is indicated, in which a cannula is inserted into the mediastinum. Air can then be expelled in this manner.
Outlook and prognosis
The prognosis of mediastinal emphysema depends on the classification of the disease. A distinction is made between spontaneous and nonspontaneous mediastinal emphysema. The prognosis for spontaneous emphysema is favorable. Nevertheless, medical treatment should take place to avoid complications. Symptomatic treatment takes place until freedom from symptoms can be documented. Spontaneous healing can be observed in a large number of patients. The air finds its way out of the organism independently and without further measures. Only in severe cases surgical intervention is necessary. This is associated with risks and can lead to secondary disorders.Nevertheless, it is usually a routine procedure that is mostly performed without interference. In the case of nonspontaneous mediastinal emphysema, the prognosis is usually unfavorable due to the overall situation. Pre-existing conditions are present that lead to severe health impairment. The patient’s condition is classified as life-threatening. In the event of an unfavorable course, the affected person will therefore die prematurely. Provided the acute condition is successfully overcome, further therapy is required. Control examinations must take place and a regression of the symptoms must be prevented. In addition, the causative disease must continue to be treated until freedom from symptoms can be established. If a recurrence of symptoms occurs here, the prognosis worsens by another.
Prevention
The human lung is a complicated organ that performs a vital function – the absorption of oxygen from the air. For this reason, it is urgent not to impair its function. The lungs can be damaged by a wide variety of influences. In mediastinal emphysema, for example, there is often irreversible expansion of the smallest areas of the lung. In principle, the causes of mediastinal emphysema must be eliminated or prevented, if this is possible. Mediastinal emphysema cannot be prevented in any other way.
Follow-up
Follow-up visits are dependent on the severity of symptoms for those affected with mediastinal emphysema. Individualized follow-up care is arranged to reduce symptoms in the long term. To this end, it must be clarified whether there are any pre-existing conditions that have caused the condition – if these are treated appropriately and the patient shows recovery, follow-up care is sometimes complete in that case. In general, sport is considered to be an effective remedy for respiratory problems, as the body is more able to cope with stress and the lung volume is exercised. A so-called DMP (disease management program), which should be carried out 1 time per quarter in a doctor’s office, provides information about the condition of the lungs and bronchial tubes. Sometimes drug treatment is necessary until the pressure in the mediastinal area subsides and has dropped to the desired levels. To that point, patients should take it easy and see their treating physician regularly to monitor the healing process more closely. Exercise in the fresh air for at least one hour daily is recommended.
Here’s what you can do yourself
Mediastinal emphysema usually does not require treatment by the physician or the patient. Normally, the air is absorbed by the surrounding tissue, and any symptoms and discomfort disappear along with it. If high pressure builds up in the mediastinal area, treatment is indicated. In most cases, a minimally invasive procedure must be performed. Surgery can best be supported by following the doctor’s instructions regarding dietary measures and physical exercise. Should complications arise, the most important measure is to see the doctor immediately. Self-treatment should be refrained from in case of shortness of breath or pain in the mediastinal area. In cases of severe pain, drug therapy can often be supported by home remedies such as cooling and heat. Devil’s claw and other pain-relieving preparations are available from naturopathy. In any case, the patient should have the wound and the course of the mediastinal emphysema checked again by the responsible physician. Accompanying this, the cause of the disease must be determined. In this way, the development of further mediastinal emphysema can be reliably avoided.
