A 13-Year-Old Athlete With Chest Pain, Cough After Practice

Daniel Beardmore, DO; Sonika Loona, MD; Mia Mallon, MD


March 01, 2022

Treatment for pneumomediastinum and any further spread of air throughout the chest and neck, including pneumorrhachis, is symptomatic and for comfort, and includes analgesics for pain. Although these patients may have respiratory signs and symptoms, positive pressure (eg, continuous positive airway pressure, nonrebreather mask) should be avoided because high airway pressures can worsen the air leak. Nasal cannula with FiO2 greater than room air may be given for hypoxia because it is low pressure. Oxygen therapy to reduce blood nitrogen partial pressure and encourage resorption of gas, so-called "nitrogen washout," may also be considered for either pneumomediastinum or pneumorrhachis. Calming an agitated or anxious patient can be very beneficial in preventing hyperventilation as well.

Surgical intervention may also be needed when persistent or intense cerebrospinal fluid leakage is present, as well as thoracic/arachnoid fistulas and lung injuries. CT-guided air aspiration through a spinal needle inserted in the neural foramen has been described. Prophylactic antibiotics are not recommended unless signs of meningitis are present.

The patient in this case was admitted to the general medical floor for conservative management. General surgery and neurosurgery were consulted, and both recommended observation until resolution of clinical symptoms. Follow-up imaging was not recommended. The patient was discharged on hospital day 2 in stable condition; he was breathing comfortably, and no further pain was elicited in his chest or neck, even with deep breathing. His thoracic inlet and neck crepitus was noted to have resolved at the time of discharge. He was recommended to refrain from sports, gym class, or other strenuous physical activity until clearance at an outpatient follow-up, scheduled within the week.


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