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Published on: January 12, 2019
Management and Outcomes of Spontaneous Pneumomediastinum in Children
Kathleen A Noorbakhsh1, Allison E Williams1, Joseph J W Langham
1From the Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.
Insights
Pediatric spontaneous pneumomediastinum can often be managed conservatively with observation. Further diagnostic imaging after initial diagnosis rarely provides additional useful information for these patients.
Area of Science:
- Pediatric Emergency Medicine
- Thoracic Imaging
- Diagnostic Yield Analysis
Background:
- Spontaneous pneumomediastinum management in children lacks standardization.
- Limited data exist on diagnostic test utility and admission necessity.
- Characterizing pediatric spontaneous pneumomediastinum is crucial for evidence-based care.
Purpose of the Study:
- To characterize the management of pediatric spontaneous pneumomediastinum.
- To determine the diagnostic yield of advanced imaging modalities.
- To describe patient outcomes and identify conservative management strategies.
Main Methods:
- Retrospective cohort study of 183 pediatric patients diagnosed with pneumomediastinum.
- Patient identification via billing codes and radiology database keyword search.
- Analysis of diagnostic imaging, subsequent investigations, and patient disposition.
Main Results:
- Chest radiograph confirmed diagnosis in 90% of patients.
- Additional imaging (CT, esophagram, laryngoscopy) yielded no new diagnostic information.
- Seventy-eight percent of patients were admitted; no invasive interventions were performed.
Conclusions:
- Clinically stable pediatric patients with spontaneous pneumomediastinum can be managed conservatively with observation.
- Avoiding unnecessary radiation exposure from further imaging is recommended.
- Conservative management can prevent invasive procedures and reduce healthcare costs.
Objectives:
Management of spontaneous pneumomediastinum in the pediatric population is highly variable. There are limited data on the use of diagnostic tests and the need for admission. Our objectives were to characterize the management of pediatric spontaneous pneumomediastinum, determine the diagnostic yield of advanced imaging, and describe the patients' outcomes.
Methods:
This is a retrospective cohort study of all patients presenting to a single tertiary pediatric emergency department between January 2008 and February 2015 diagnosed with pneumomediastinum. Patients were identified using 2 complementary strategies: International Classification of Diseases, Ninth Revision billing codes and a keyword search of the hospital radiology database.
Results:
We identified 183 patients with spontaneous pneumomediastinum. The mean age was 12.8 ± 4.8 years. Diagnosis was established by chest radiograph (CXR) in 165 (90%) patients, chest computed tomography in 15 (8%), neck imaging in 2 (1%), and abdominal imaging in 1. After diagnosis, many patients underwent additional studies: repeat CXR (99, 54%), chest computed tomography (53, 29%), esophagram (45, 25%), and laryngoscopy (15, 8%). Seventy-eight percent of patients (n = 142) were admitted with a median length of stay of 27 hours (18.4-45.6 hours). Six patients returned to the emergency department within 96 hours for persistent chest pain; 2 were admitted, and 1 was found to have worsening pneumomediastinum on CXR. We performed a secondary analysis on 3 key subgroups: primary spontaneous pneumomediastinum (64, 35%), secondary gastrointestinal-associated pneumomediastinum (31, 17%), and secondary respiratory-associated pneumomediastinum (88, 48%). No patients in the study received an invasive intervention for pneumomediastinum. In all patients, further studies did not yield additional diagnostic information.
Conclusions:
Our data suggest that patients with spontaneous pneumomediastinum who are clinically well appearing can be managed conservatively with clinical observation, avoiding exposure to radiation and invasive procedures.
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