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PubMed2005

Advanced anorexia nervosa, associated with pneumomediastinum, pneumothorax, and soft-tissue emphysema without esophageal lesion.

OBJECTIVE: We describe the case of a 20-year-old female patient suffering from anorexia nervosa since the age 15 of years. When admitted, she was 168 cm tall with a weight of 35 kg (body mass index [BMI] = 12.4). A week after admission, the patient complained of retrosternal pain, and a few hours later she developed extensive soft-tissue emphysema. METHODS: The X-ray picture of her thorax showed left-hand supraclavicular and infraclavicular emphysema, extensive emphysema in both sides of the soft tissue of the throat, a left-hand apical pneumothorax (4 mm), and a pneumomediastinum. RESULTS: We discuss the extent to which these symptoms are interrelated in the sense of a causal nexus. CONCLUSION: We ruled out any other differential-diagnostic etiopathogenic factors and concluded that the cause of our patient's soft-tissue emphysema, pneumothorax, and pneumomediastinum might well be autodestructive behavior.

Adult↗
PubMed1979

Subcutaneous emphysema of the abdominal wall from diverticulitis with necrotizing fasciitis.

The case history of a patient with subcutaneous emphysema of the abdomen from sigmoid diverticulitis is presented. The mechanisms for developing abdominal wall emphysema are reviewed. Thus when the gas originates from the gastrointestinal tract, mechanical factors are mainly responsible for this phenomenon. These inculde a direct communication through a colonocutaneous fistula. Gas may, however, also be spread into the abdominal wall by high intraintestinal pressures. Infection with gas-producing organisms may be associated with subcutaneous emphysema. This is particularly true when the emphysema develops 48 h or longer after onset of symptoms. Infection, however, is not the major cause for gas in these tissues.

Abdominal Muscles↗
PubMed1997

Spontaneous epidural emphysema and pneumomediastinum during an asthmatic attack in a child.

CT revealed the presence of epidural emphysema as an incidental finding in a 13-year-old boy in whom mild infrequent coughing during an asthmatic attack resulted in a pneumomediastinum and subcutaneous emphysema. Epidural emphysema was not associated with neurological symptoms. The CT images demonstrated the pathway of air leakage from the posterior mediastinum through the intervertebral foramina into the epidural space. Repeat CT showed spontaneous resolution of the epidural emphysema.

Adolescent↗
PubMed2003

Benign noninfectious subcutaneous emphysema of the hand.

A 17-year-old girl presented pain and subcutaneous crepitation in the left hand. Because of lack of systemic symptoms, non-infectious cause was considered. Radiographic and magnetic resonance imaging revealed subcutaneous emphysema. A chest x-ray was reported as normal but chest computerised tomography revealed pneumomediastinum. On the third day of the hospitalisation, subcutaneous emphysema spread to arm, shoulder, head, left hemithorax, back, bilateral supraclavicular, cervical, submandibular and periorbital regions. Pneumomediastinum and subcutaneous emphysema disappeared during 6 weeks of follow up with conservative methods. This might have prevented unnecessary surgical intervention. This report demonstrates that benign non-infectious subcutaneous emphysema of the hand due to pneumomediastinum should be kept in mind in hand surgery.

Adolescent↗
PubMed2004

Pneumomediastinum and soft tissue emphysema of the neck in postmortem CT and MRI; a new vital sign in hanging?

Spontaneous pneumomediastinum commonly occurs in healthy young men or parturient women in whom an increased intra-alveolar pressure (Valsalva maneuver, asthma, cough, emesis) leads to the rupture of the marginal pulmonary alveoli. The air ascends along the bronchi to the mediastinum and the subcutaneous space of the neck, causing cervico-fascial subcutaneous emphysema in 70-90% of cases. Ninety-five forensic cases, including five cases of hanging, were examined using postmortem multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) prior to autopsy until December 2003. This paper describes the findings of pneumomediastinum and cervical emphysema in three of five cases of hanging. The mechanism of its formation is discussed based on these results and a review of the literature. In conclusion, when putrefaction gas can be excluded the findings of pneumomediastinum and cervical soft tissue emphysema serve as evidence of vitality of a hanged person. Postmortem cross-sectional imaging is considered a useful visualization tool for emphysema, with a great potential for examination and documentation.

Adult↗
PubMed1999

Subcutaneous emphysema and pneumomediastinum after dental extraction.

Pneumomediastinum, pneumothorax, and subcutaneous emphysema can occur occasionally after a surgical procedure. Facial swelling is a common complication of dental management. The occurrence of subcutaneous emphysema, pneumothorax, and pneumomediastinum after dental procedures is rare. We present a case with subcutaneous emphysema of the upper chest, neck, chin, and pneumomediastinum after a tooth extraction and discuss the possible mechanism of subcutaneous emphysema. To prevent these complications during dental procedures, dental hand pieces that have air coolant and turbines that exhaust air in the surgical field should not be used.

Adult↗
PubMed1999

Subcutaneous emphysema with spontaneous pneumomediastinum and pneumothorax in adult dermatomyositis.

We describe a 32-year-old patient with adult dermatomyositis who developed dyspnea and worsening of pre-existing infarcted skin lesions of the fingers. Chest radiographs showed diffuse hazy reticulonodular infiltration in both lungs, subcutaneous emphysema, pneumomediastinum, and pneumothorax. The pulmonary symptoms and cutaneous lesions gradually improved with a high dose of prednisolone. Although subcutaneous emphysema and pneumomediastinum occur frequently in association with traumatic disruption of cutaneous and mucosal barriers and assisted ventilation, it has rarely been observed in patients with interstitial pneumonitis in connective tissue diseases. Although dermatomyositis and subcutaneous emphysema are all relatively well-known diseases to dermatologists, the occurrence of spontaneous pneumomediastinum and pneumothorax and subsequent subcutaneous emphysema in connective tissue diseases such as dermatomyositis is unfamiliar. We discuss the possible mechanisms of this condition.

Adult↗
PubMed2002

Hemodynamic characterization of patients with severe emphysema.

In 120 patients with severe emphysema evaluated for participation in the National Emphysema Treatment Trial, pulmonary hemodynamics and ventricular function were assessed. Pulmonary function tests were (%predicted): FEV(1) = 27%; residual volume = 224.6%; diffusion capacity = 26.7%. In 90.8% of patients, end-expiratory pulmonary artery mean pressure was > 20 mm Hg; in 61.4%, end-expiratory wedge pressure was > 12 mm Hg. Cardiac index was normal. Mean pulmonary artery pressure correlated inversely with arterial PO(2), and severity of emphysema, and directly with wedge pressure. Multiple stepwise regression revealed that arterial PO(2) was not an independent predictor of mean pulmonary artery pressure. No correlation was found between indices of emphysema severity and PA pressures. Diastolic ventricular pressures were increased without evidence of systolic dysfunction. We conclude that (1) elevations of pulmonary vascular pressures are common, (2) pulmonary hypertension may be related to factors other than hypoxia, (3) pulmonary hypertension does not impair resting systemic O(2) delivery, and (4) elevated cardiac diastolic pressures do not represent systolic dysfunction.

Aged↗
PubMed1986

Extensive subcutaneous emphysema crossing the midline after a surgical extraction: report of case.

A case of extensive subcutaneous emphysema is reported. The patient had a mandibular third molar extracted but did not experience any cervical edema until the morning after surgery. The emphysema did not appear to be caused by the surgical procedure, as emphysema caused by use of instruments becomes immediately apparent and no patient-related causes could be documented. However, a dressing of a tetracycline-steroid ointment in a petrolatum base and a hemostatic agent was placed in the tooth socket during surgery and the dressing may have allowed air into the deeper tissues. The patient was managed by hospitalization, antibiotic therapy, and rest. The tissue emphysema resolved gradually during a 5-day period.

Adult↗
PubMed1987

Interstitial emphysema associated with epidural anesthesia for extracorporeal shock-wave lithotripsy.

Interstitial emphysema was noted on abdominal radiographs in 38 (15%) of the first 150 patients treated by extracorporeal shock-wave lithotripsy at our hospital. All 38 patients had undergone successful or attempted epidural anesthesia for the lithotripsy. This finding was not seen in any patient who had not undergone epidural puncture. The emphysema is the result of the introduction of air into the paraspinal and back muscles or subcutaneous tissues during attempted or actual puncture of the epidural space. This air was apparent on abdominal radiographs taken after lumbar puncture in 38 (23%) of 167 patients who underwent attempted or actual puncture of the epidural space. The emphysema decreases over the ensuing days, is of no clinical significance, and bears no direct relationship to extracorporeal shock-wave lithotripsy. This finding should not be mistaken for emphysema caused by gas-producing or gas-containing retroperitoneal diseases.

Anesthesia, Epidural↗
PubMed1981

Massive subcutaneous emphysema: an unusual presentation of jejunal perforation.

Massive diffuse subcutaneous emphysema resulting from perforation of the proximal jejunum is presented. Seventy-nine reported instances of subcutaneous emphysema of gastrointestinal origin were reviewed. Emphysema originating from the jejunum has not been previously reported. The colon (26 patients) and rectum (16 patients) were the more common sites of perforation. Perforations of the stomach and duodenum were found in 14 patients. The most common site for presentation of the subcutaneous air was the lower abdominal wall and thigh, and the more common causes were carcinoma of the colon and rectum and diverticulitis. The pathogenesis of emphysema in the patient described, as well as in the great majority of other patients, is from intraluminal gas rather than from gas-forming organisms. The air spreads along neurovascular bundles and other anatomic planes and may rapidly reach areas distant from the perforation. The recognition of these phenomena in the diagnosis of gastrointestinal perforation is important.

Clostridium Infections↗
PubMed2005

Soft tissue cervicofacial emphysema after dental treatment: report of 2 cases with emphasis on the differential diagnosis of angioedema.

BACKGROUND: The development of soft tissue cervicofacial emphysema after dental treatment is a rare complication, with few descriptions in the dermatologic literature. It is usually restricted to only moderate local swelling. However, spread of larger amounts of air into deeper spaces may sometimes cause serious complications, including airway compromise due to accumulation of air in the retropharyngeal space, pneumomediastinum, and pneumopericardium. Fatal air embolism and soft tissue infections through dissemination of oral flora microorganisms along the emphysematous tracts have also been described. Therefore, early recognition is important, but the unfamiliarity of dermatologists with this condition often causes diagnostic problems. Important differential diagnoses include angioedema, soft tissue infections, and hematoma. OBSERVATIONS: We describe 2 patients with different severity of the emphysema and airway compromise, representing the wide spectrum of its clinical expression. Our first case was remarkable, because the emphysema was massive and extended far into deep spaces, including the orbita, mediastinum, and pleural cavity. The present case is only the third report of pneumothorax associated with dental treatment published to date. The patient's condition was initially misdiagnosed and treated as angioedema. CONCLUSIONS: Dermatologists should be aware that soft tissue emphysema can cause acute swelling of the cervicofacial region after dental procedures. Angioedema is an important differential diagnosis, because it may be caused by the use of nonsteroidal anti-inflammatory drugs or local anesthetics, which are often administered during dental treatments.

Adult↗
PubMed2006

Lung volume reduction surgery for diffuse emphysema.

BACKGROUND: Lung volume reduction surgery (LVRS) has been re-introduced for treating patients with severe diffuse emphysema. It is a procedure that aims to improve long-term daily functioning, although it is costly and may also be associated with a high risk of mortality. OBJECTIVES: To assemble evidence from randomised controlled trials for the effectiveness of LVRS, and identify optimal surgical techniques. SEARCH STRATEGY: Randomised controlled trials were identified using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register. Searches are current to September 2005. SELECTION CRITERIA: Randomised controlled trials that studied the safety and efficacy of LVRS in patients with diffuse emphysema were included. Studies were excluded if they investigated giant or bullous emphysema. DATA COLLECTION AND ANALYSIS: Two independent review authors assessed trials for inclusion and extracted data. Where possible, data from more than one study were combined using RevMan 4.2 software. MAIN RESULTS: Eight studies (1663 participants) met the entry criteria of the review. One study accounted for 73% of the participants recruited. Study quality was high, although blinding in studies was not possible. Ninety day mortality was significantly greater in all those who underwent LVRS (odds ratio 6.57 (95% CI 3.34 to 12.95), four studies, N = 1415). A subgroup analysis by risk status suggested that there was a subgroup of participants who were consistently at a significant risk of death, although this was only measured in one large study. The ninety day mortality data indicated that death was more likely with LVRS irrespective of risk status identified in one large study. Improvements in lung function, quality of life and exercise capacity were more likely with LVRS than with usual follow-up. AUTHORS' CONCLUSIONS: The evidence summarised in this review is drawn from one large study, and several smaller trials. The findings from the large study indicated that in patients who survive up to three months post-surgery, there were significantly better health status and lung function outcomes in favour of surgery compared with usual medical care. Patients identified post hoc as being of high risk of death from surgery were those with particularly impaired lung function and poor diffusing capacity and/or homogenous emphysema. Further research should address the effect of this intervention on exacerbations and rate of decline in lung function and health status.

Emphysema↗
PubMed2003

Congenital lobar emphysema: evaluation and long-term follow-up of thirty cases at a single center.

Congenital lobar emphysema (CLE) is characterized by overdistension and air-trapping in the affected lobe, and is one of the causes of infantile respiratory distress. In this report, we review our 27 years of experience with 30 CLE patients. Patients' medical records were evaluated with regard to age, clinical presentation, diagnostic methods, associated diseases, treatment, histopathologic findings, and final clinical and laboratory findings at the end of a long-term period. The mean age of 30 patients (18 male) at diagnosis was 4.9 +/- 6.7 months (range, 2 days-2.5 years). Tachypnea, dyspnea, cough, cyanosis, wheezing, hoarseness, and decreased breath sounds on the affected side were the main symptoms and clinical findings. On chest X-rays, emphysema was seen in all patients; shift/herniation to the opposite lung, atelectasis, and pneumothorax were observed in 16, 5, and 2 cases, respectively. Computerized tomography of the thorax was performed in 16 cases and revealed emphysema at affected lobe/lobes in all, a shift/herniation to the opposite side in 12 cases, and atelectasis of neighbor lobe/lobes in 7 cases. All 8 patients who had perfusion scintigraphy showed reduced perfusion in the affected lobe. Narrowed and flaccid bronchi were detected in one patient by using flexible bronchoscopy. Blood gas analysis was performed in 11 patients, and hypoxia and hypercarbia were revealed in 9 and 7 of these patients, respectively. The most common affected lobe was the left upper lobe (57%), followed by the right upper lobe (30%) and right middle lobe (27%). Two lobes were involved in 4 patients. Associated abnormalities were observed in 5 patients. Twenty-one patients underwent lobectomy; 9 were followed conservatively. Ages at diagnosis were significantly younger in surgically treated patients. Emphysema was detected in all pathological specimens, with an additional bronchial cartilage deficiency in 2 patients. In the surgically treated group, 2 patients died and 2 patients were lost to follow-up. In the conservatively treated group, one patient was lost to follow-up. Mean follow-up duration of all patients was 63.2 +/- 56.2 months (range, 1-209 months). At follow-up visits, all patients were doing well. In surgically treated patients, chest X-rays were normal (9 cases), or showed hyperlucency on the operated side (6 cases) or chronic changes in the operation area (2 cases). Hyperexpansion in the affected lobe was found to be reduced in all cases in the conservatively treated group.

Adolescent↗
PubMed1995

Successful treatment of severe neonatal lobar emphysema by high-frequency oscillatory ventilation.

We successfully used high-frequency oscillatory ventilation (HFOV) for treating severe acquired lobar emphysema in two premature newborn infants (birth weights, 1,450 and 1,300 g). After successful weaning from mechanical ventilation for hyaline membrane disease, they needed additional ventilatory support because they developed severe lobar emphysema compressing the residual lung. In both patients, radiographic signs of lobar emphysema disappeared completely after 3 days of HFOV. Diagnosis and follow-up were confirmed by high-resolution computed tomography. We conclude that HFOV may be a useful noninvasive method for treating severe lobar emphysema.

High-Frequency Ventilation↗
PubMed2005

Quantification of emphysema severity by histogram analysis of CT scans.

Emphysema is characterized by the destruction and over distension of lung tissue, which manifest on high resolution computer tomography (CT) images as regions of low attenuation. Typically, it is diagnosed by clinical symptoms, physical examination, pulmonary function tests, and X-ray and CT imaging. In this paper we discuss a quantitative imaging approach to analyze emphysema which employs low-level segmentations of CT images that partition the data into perceptually relevant regions. We constructed multi-dimensional histograms of feature values computed over the image segmentation. For each region in the segmentation, we derive a rich set of feature measurements. While we can use any combination of physical and geometric features, we found that limiting the scope to two features - the mean attenuation across a region and the region area - is effective. The subject histogram is compared to a set of canonical histograms representative of various stages of emphysema using the Earth Mover's Distance metric. Disease severity is assigned based on which canonical histogram is most similar to the subject histogram. Experimental results with 81 cases of emphysema at different stages of disease progression show good agreement against the reading of an expert radiologist.

Algorithms↗
PubMed1993

[123I]HIPDM pulmonary imaging demonstrates elastase-induced pulmonary emphysema.

Because more than 90 percent of [123I]hydroxyiodobenzyl-propanediamine (HIPDM) is localized in the lung after intravenous injection, the radiopharmaceutical has been proposed as a lung imaging agent. Its potential usefulness for the detection of pulmonary emphysema was evaluated in an animal model of elastase-induced emphysema along with [99mTc]MAA lung perfusion imaging. To induce lung emphysema, Long-Evans rats (200-250 g) were given 400 IU/Kg elastase intratracheally under ether anesthesia. Four weeks after elastase treatment, 15 treated and 15 nontreated rats were paired and simultaneously imaged under a scintillation camera immediately following intravenous injection of 0.25-0.3 mCi[99mTc]MAA. The procedure was repeated 48 hr later using 0.25-0.3 mCi[123I]HIPDM. Activity in the region of interest (ROI) over the lungs was recorded after the injections. Total counts per ROI from each rat were measured and normalized by lung volume. The normalized lung activity ratio of treated/nontreated rats was computed. The mean ratios of HIPDM and MAA were 0.847 and 0.802, respectively. The significant decrease in uptake of both HIPDM (p < 0.021) and of MAA (p < 0.025) in the elastase-treated lungs indicates decrease in functioning vascular endothelium and decrease in number of pulmonary capillary vessels, respectively, reflecting damage in capillaries and small arterioles. The decrease in treated/nontreated ratios lung is consistent with a significant alteration in pulmonary function and a significant increase in mean linear intercept (p < 0.005) in treated lung. Since the imaging reflects pulmonary endothelial receptor function, [123I]HIPDM lung imaging may serve as an alternative diagnostic modality for pulmonary emphysema.

Animals↗
PubMed1995

Lobar emphysema associated with respiratory syncytial virus pneumonia.

The etiology of infantile lobar emphysema is frequently unknown; however, partial airway obstruction is most often implicated. Although infection and lobar emphysema have been linked previously, their cause-and-effect relationship is unclear. We present the clinical, radiographic, and pathologic findings in a 9-day-old infant with acute bronchiolitis due to respiratory syncytial virus (RSV) and a clinical and radiographic appearance suggestive of lobar emphysema. Pathologically, there was diffuse papillary overgrowth of the bronchiolar epithelium due to RSV infection which produced narrowing of the affected airways and alveolar overinflation. We speculate that in this instance RSV infection was at least associated with the development, and was perhaps the direct cause of lobar emphysema.

Bronchiolitis, Viral↗