The image above shows pneumomediastinum (blue arrow), subcutaneous emphysema (red arrows), and small biapical pneumothoracies (purple arrows). Common causes include barotrauma (asthmatics with cough, crack smoking with coughing against a closed glottis), Boerhaave syndrome (rupture of the esophagus due to iatrogenesis or with forceful vomiting), and spontaneous pneumomediastinum (more rare, seen in younger people). Air may track up around the vocal cords, or even down into the abdomen. Hoarse or "nasal" voice are common, and subcutaneous emphysema may be noted over the neck and chest. Hamman's cruch is a crunching shound heard over the precordium with the cycle of the heartbeat.
Spontaneous pneumomediastinum is rare and self limited. Boerhaeve's syndrome is a life threatening condition, and these patients should be started on broad spectrum antibiotics with immediate cardiothoracic surgical consultation. Diagnosis may be made by CT scan of the thorax or gastrograffin swallow, but if this is suspected do not let these studies delay antibiotics and early surgical consultation.
A 58 year old male is brought to the ED after being found SOB and hypoxic. He has a history of alcohol abuse and cardiac disease, and EMS states they think he has CHF. His hypoxia improved with CPAP. You obtain the following CXR. What is causing his shortness of breath and hypoxia? Based on this XR, what is the likely root cause? How can you tell if lung white out on a CXR is related to volume loss versus effusion? If the patient was hypotensive, based on this X Ray, what might be the cause?