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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Axial view computed tomography of chest &#40;mediastinal window&#41; showing pneumomediastinum &#40;red arrows&#41; and subcutaneous emphysema &#40;white arrows&#41;&#46; &#40;B&#41; Axial view computed tomography of chest &#40;lung window&#41; showing pneumomediastinum &#40;red arrows&#41;&#44; subcutaneous emphysema &#40;white arrows&#41; and left basal pneumothorax &#40;yellow arrows&#41;&#46; &#40;C&#41; Sagittal view computed tomography of chest &#40;lung window&#41; showing pneumomediastinum &#40;red arrows&#41;&#44; subcutaneous emphysema &#40;white arrows&#41; and complete collapse of trachea distal to endotracheal tube &#40;ETT&#41; tip &#40;green arrows&#41;&#46; &#40;D&#41; Bronchoscopic view showing complete collapse of anterior tracheal wall &#40;blue arrows&#41; typical of tracheomalacia&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We would like to commend Gutierrez-Morales et al&#46; on their interesting case presentation of spontaneous pneumomediastinum in an asthmatic patient published in your esteemed journal&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> We wish to extend the spectrum of this rare phenomenon presenting with perplexing clinical and radiological findings which make the management and decision making a challenging task&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 62-year-old man in the medical ICU was being treated for alleged asthma exacerbation&#46; He has had no past admissions for asthma exacerbation&#46; On clinical examination his blood pressure was 114&#47;86<span class="elsevierStyleHsp" style=""></span>mm HG with heart rate of 96 beats per minute&#46; He was saturating 97&#37; on 50&#37; FiO<span class="elsevierStyleInf">2</span> on bi-level non-invasive ventilation for his work of breathing&#46; Chest auscultation revealed prolonged expiratory phase with shortness of breath worse in supine position&#46; There was equal but diminished air entry on both sides with equal chest wall movement&#46; There was no subcutaneous crepitus on palpitation&#46; During treatment with non-invasive ventilation patient developed subcutaneous emphysema &#40;extensive subcutaneous crepitus&#41; and progressive shortness of breath requiring intubation and mechanical ventilation&#46; Extensive subcutaneous crepitus was noted on palpation as well as on auscultation of the chest and precordium &#40;Hammond&#39;s crunch&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Chest X-ray done at the time showed extensive subcutaneous emphysema&#46; Due to progressive shortness of breath and hypoxia&#44; patient was intubated and pharmacological paralysis was induced to aid effective ventilation&#46; Computed tomography &#40;CT&#41; of the chest showed severe subcutaneous emphysema &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#47;B&#47;C white arrows&#41;&#44; moderate to severe pneumomediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#47;B&#47;C red arrows&#41; and moderate sized left basal pneumothorax &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B yellow arrows&#41;&#46; Interestingly reporting radiologist also noted complete collapse of the trachea distal to the endotracheal tube &#40;ETT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C green arrow&#41; and suggested tracheal&#47;bronchial rupture as a differential diagnosis in the current clinical context&#46; However&#44; there was no loss of peak or plateau airway pressures on the mechanical ventilator&#46; At this point&#44; patient&#39;s oxygen requirements had increased requiring 100&#37; FiO2 for optimal oxygen saturation with hypotension with systolic blood pressure of 90<span class="elsevierStyleHsp" style=""></span>mm Hg&#46; Urgent surgical consultation was sought and patient was anticipated to undergo extra corporeal membrane oxygenation &#40;ECMO&#41; prior to surgical correction of suspected tracheal rupture&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Patient underwent emergency bronchoscopy which showed collapsed trachea distal to the ETT tip classic for tracheomalacia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D blue arrows&#41;&#46; Focused bronchoscopic examination until the second generation bronchi bilaterally did not reveal any airway wall rupture&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It was concluded that the patient most likely had tracheomalacia which was probably diagnosed as acute asthma exacerbation&#46; The positive airway pressure ventilation most likely caused barotrauma and leading to pneumothorax&#44; pneumomediastinum and extensive subcutaneous emphysema leading to hypoxic respiratory failure&#46; Our patient subsequently underwent tube thoracostomy for left sided pneumothorax and conservative management for pneumomediastinum&#46; He was extubated 7 days later and made complete recovery&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Spontaneous pneumomediastinum &#40;SPM&#41; is also known as Hamman&#39;s syndrome&#46; SPM is a rare entity and is characterized by air leak into the mediastinum&#44; not secondary to any underlying disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> It was first described by Macklin as &#8220;<span class="elsevierStyleItalic">the transference of air along sheaths of pulmonic blood vessels from alveoli to</span><span class="elsevierStyleItalic">mediastinum</span>&#8221; it can be shortened as follows&#58; alveolar ruptures leading to air dissection along bronchovascular sheaths&#44; and spreading into the mediastinum&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Hamman&#39;s syndrome is not a life-threatening condition and&#44; once diagnosed&#44; may require only supportive and symptomatic therapy&#44; which includes oxygen&#44; analgesics and sedatives as necessary&#44; unless it is associated with tension pneumothorax and&#47;or hemodynamic instability as noted in our patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4&#8211;7</span></a> Secondary pneumomediastinum can be differentiated from SPM when a causative factor is identified&#46; It could be iatrogenic &#40;endoscopic procedures&#44; airway manipulation such as during endotracheal intubation&#44; pleural cavity instrumentation&#44; central venous access procedures&#44; blunt or penetrating trauma&#44; inhalation of toxic fumes etc&#46;&#41;&#46; Addressing the underlying cause usually should suffice and conservative management would be the choice of treatment&#46; However&#44; in rare cases the simple pneumomediastinum can progress to a malignant one and can lead to hemodynamic instability due to cardiac tamponade and occasionally airway compromise&#46; In these cases video-assisted thoracoscopic surgery becomes an indispensable tool for decompression and attaining hemodynamic stability&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Due to its acute presentation and often other concomitant illnesses&#44; spontaneous pneumomediastinum creates a cause of worry for the treating physicians&#46; Quest for diagnosis and underlying cause is of prime importance&#44; since it has an impact on overall prognosis and management plans&#46; Chest X rays and CT scans are the investigative modalities of choice for a conclusive diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8-10</span></a> Despite better visualization of structures on CT chest&#44; there are instances where the source of free air in the mediastinum has been misdiagnosed&#46; Brussa et al&#46; described a case of spontaneous pneumomediastinum in a pregnant patient&#44; CT scan of the chest was over-read as possible tracheal rupture but bronchoscopy was able to avert the unnecessary surgical exploration&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Bronchoscopy often provides precious diagnostic information in critically ill patients where the cause of hypoxia is elusive&#44; such as lobar torsion after surgery&#44; mucus plugging and lung collapse&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">12</span></a> Similar mistake occurred in the radiological assessment of our patient which triggered a need for a major surgical intervention and possibly ECMO&#46; In our case too&#44; bronchoscopy was able to provide a more accurate diagnosis and eliminate the doubts of tracheal rupture&#46; It is understandable though&#44; that in a subset of critically ill patients&#44; requiring high fraction of inspired oxygen and positive end expiratory pressure &#40;PEEP&#41;&#44; bedside bronchoscopy may not be an available option&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Our case highlights a few important teaching points&#46; Firstly&#44; misdiagnosis of tracheomalacia as asthma exacerbation led to anchoring bias which changed the trajectory of treatment&#46; Secondly&#44; radiological misreading of tracheomalacia as possible tracheal&#47;bronchial rupture almost resulted in unnecessary major surgical intervention&#46; Traumatic intubation can lead to pneumothorax&#44; pneumomediastinum and respiratory failure&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">13</span></a> Accuracy in radiological reading is highly desirable in such cases&#44; however&#44; there have been instances where over-reading may result in possible &#40;unnecessary&#41; surgical intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Pneumomediastinum is an alarming condition and can be associated with high mortality if infection ensues&#44; despite surgical management&#46; Bronchoscopy should be strongly considered before committing to surgical intervention when tracheal wall rupture is suspected on CT scan to confirm diagnosis and negate erroneous reading&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;11</span></a></p></span>"
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Scientific letter
Spontaneous Pneumomediastinum: Rare Complication of Tracheomalacia
Neumomediastino espontáneo: una complicación infrecuente de la traqueomalacia
Amos Lala,
Corresponding author
Lal.Amos@mayo.edu

Corresponding author.
, Ajay Kumar Mishrab, Kamal Kant Sahub, Mohsen Noreldinb
a Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
b Department of Internal Medicine, Saint Vincent Hospital, Massachusetts, USA
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Axial view computed tomography of chest &#40;mediastinal window&#41; showing pneumomediastinum &#40;red arrows&#41; and subcutaneous emphysema &#40;white arrows&#41;&#46; &#40;B&#41; Axial view computed tomography of chest &#40;lung window&#41; showing pneumomediastinum &#40;red arrows&#41;&#44; subcutaneous emphysema &#40;white arrows&#41; and left basal pneumothorax &#40;yellow arrows&#41;&#46; &#40;C&#41; Sagittal view computed tomography of chest &#40;lung window&#41; showing pneumomediastinum &#40;red arrows&#41;&#44; subcutaneous emphysema &#40;white arrows&#41; and complete collapse of trachea distal to endotracheal tube &#40;ETT&#41; tip &#40;green arrows&#41;&#46; &#40;D&#41; Bronchoscopic view showing complete collapse of anterior tracheal wall &#40;blue arrows&#41; typical of tracheomalacia&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We would like to commend Gutierrez-Morales et al&#46; on their interesting case presentation of spontaneous pneumomediastinum in an asthmatic patient published in your esteemed journal&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> We wish to extend the spectrum of this rare phenomenon presenting with perplexing clinical and radiological findings which make the management and decision making a challenging task&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 62-year-old man in the medical ICU was being treated for alleged asthma exacerbation&#46; He has had no past admissions for asthma exacerbation&#46; On clinical examination his blood pressure was 114&#47;86<span class="elsevierStyleHsp" style=""></span>mm HG with heart rate of 96 beats per minute&#46; He was saturating 97&#37; on 50&#37; FiO<span class="elsevierStyleInf">2</span> on bi-level non-invasive ventilation for his work of breathing&#46; Chest auscultation revealed prolonged expiratory phase with shortness of breath worse in supine position&#46; There was equal but diminished air entry on both sides with equal chest wall movement&#46; There was no subcutaneous crepitus on palpitation&#46; During treatment with non-invasive ventilation patient developed subcutaneous emphysema &#40;extensive subcutaneous crepitus&#41; and progressive shortness of breath requiring intubation and mechanical ventilation&#46; Extensive subcutaneous crepitus was noted on palpation as well as on auscultation of the chest and precordium &#40;Hammond&#39;s crunch&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Chest X-ray done at the time showed extensive subcutaneous emphysema&#46; Due to progressive shortness of breath and hypoxia&#44; patient was intubated and pharmacological paralysis was induced to aid effective ventilation&#46; Computed tomography &#40;CT&#41; of the chest showed severe subcutaneous emphysema &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#47;B&#47;C white arrows&#41;&#44; moderate to severe pneumomediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#47;B&#47;C red arrows&#41; and moderate sized left basal pneumothorax &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B yellow arrows&#41;&#46; Interestingly reporting radiologist also noted complete collapse of the trachea distal to the endotracheal tube &#40;ETT&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C green arrow&#41; and suggested tracheal&#47;bronchial rupture as a differential diagnosis in the current clinical context&#46; However&#44; there was no loss of peak or plateau airway pressures on the mechanical ventilator&#46; At this point&#44; patient&#39;s oxygen requirements had increased requiring 100&#37; FiO2 for optimal oxygen saturation with hypotension with systolic blood pressure of 90<span class="elsevierStyleHsp" style=""></span>mm Hg&#46; Urgent surgical consultation was sought and patient was anticipated to undergo extra corporeal membrane oxygenation &#40;ECMO&#41; prior to surgical correction of suspected tracheal rupture&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Patient underwent emergency bronchoscopy which showed collapsed trachea distal to the ETT tip classic for tracheomalacia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D blue arrows&#41;&#46; Focused bronchoscopic examination until the second generation bronchi bilaterally did not reveal any airway wall rupture&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It was concluded that the patient most likely had tracheomalacia which was probably diagnosed as acute asthma exacerbation&#46; The positive airway pressure ventilation most likely caused barotrauma and leading to pneumothorax&#44; pneumomediastinum and extensive subcutaneous emphysema leading to hypoxic respiratory failure&#46; Our patient subsequently underwent tube thoracostomy for left sided pneumothorax and conservative management for pneumomediastinum&#46; He was extubated 7 days later and made complete recovery&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Spontaneous pneumomediastinum &#40;SPM&#41; is also known as Hamman&#39;s syndrome&#46; SPM is a rare entity and is characterized by air leak into the mediastinum&#44; not secondary to any underlying disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> It was first described by Macklin as &#8220;<span class="elsevierStyleItalic">the transference of air along sheaths of pulmonic blood vessels from alveoli to</span><span class="elsevierStyleItalic">mediastinum</span>&#8221; it can be shortened as follows&#58; alveolar ruptures leading to air dissection along bronchovascular sheaths&#44; and spreading into the mediastinum&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Hamman&#39;s syndrome is not a life-threatening condition and&#44; once diagnosed&#44; may require only supportive and symptomatic therapy&#44; which includes oxygen&#44; analgesics and sedatives as necessary&#44; unless it is associated with tension pneumothorax and&#47;or hemodynamic instability as noted in our patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4&#8211;7</span></a> Secondary pneumomediastinum can be differentiated from SPM when a causative factor is identified&#46; It could be iatrogenic &#40;endoscopic procedures&#44; airway manipulation such as during endotracheal intubation&#44; pleural cavity instrumentation&#44; central venous access procedures&#44; blunt or penetrating trauma&#44; inhalation of toxic fumes etc&#46;&#41;&#46; Addressing the underlying cause usually should suffice and conservative management would be the choice of treatment&#46; However&#44; in rare cases the simple pneumomediastinum can progress to a malignant one and can lead to hemodynamic instability due to cardiac tamponade and occasionally airway compromise&#46; In these cases video-assisted thoracoscopic surgery becomes an indispensable tool for decompression and attaining hemodynamic stability&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Due to its acute presentation and often other concomitant illnesses&#44; spontaneous pneumomediastinum creates a cause of worry for the treating physicians&#46; Quest for diagnosis and underlying cause is of prime importance&#44; since it has an impact on overall prognosis and management plans&#46; Chest X rays and CT scans are the investigative modalities of choice for a conclusive diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8-10</span></a> Despite better visualization of structures on CT chest&#44; there are instances where the source of free air in the mediastinum has been misdiagnosed&#46; Brussa et al&#46; described a case of spontaneous pneumomediastinum in a pregnant patient&#44; CT scan of the chest was over-read as possible tracheal rupture but bronchoscopy was able to avert the unnecessary surgical exploration&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Bronchoscopy often provides precious diagnostic information in critically ill patients where the cause of hypoxia is elusive&#44; such as lobar torsion after surgery&#44; mucus plugging and lung collapse&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">12</span></a> Similar mistake occurred in the radiological assessment of our patient which triggered a need for a major surgical intervention and possibly ECMO&#46; In our case too&#44; bronchoscopy was able to provide a more accurate diagnosis and eliminate the doubts of tracheal rupture&#46; It is understandable though&#44; that in a subset of critically ill patients&#44; requiring high fraction of inspired oxygen and positive end expiratory pressure &#40;PEEP&#41;&#44; bedside bronchoscopy may not be an available option&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Our case highlights a few important teaching points&#46; Firstly&#44; misdiagnosis of tracheomalacia as asthma exacerbation led to anchoring bias which changed the trajectory of treatment&#46; Secondly&#44; radiological misreading of tracheomalacia as possible tracheal&#47;bronchial rupture almost resulted in unnecessary major surgical intervention&#46; Traumatic intubation can lead to pneumothorax&#44; pneumomediastinum and respiratory failure&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">13</span></a> Accuracy in radiological reading is highly desirable in such cases&#44; however&#44; there have been instances where over-reading may result in possible &#40;unnecessary&#41; surgical intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Pneumomediastinum is an alarming condition and can be associated with high mortality if infection ensues&#44; despite surgical management&#46; Bronchoscopy should be strongly considered before committing to surgical intervention when tracheal wall rupture is suspected on CT scan to confirm diagnosis and negate erroneous reading&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5&#44;11</span></a></p></span>"
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ISSN: 03002896
Original language: English
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