Elsevier

Heart & Lung

Volume 39, Issue 5, September–October 2010, Pages 444-447
Heart & Lung

Case Studies in Critical Care
Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: The Macklin effect

https://doi.org/10.1016/j.hrtlng.2009.10.001Get rights and content

Objective

We describe the clinical features of a 17-year-old girl with severe asthma exacerbations. On admission to the intensive care unit, she manifested expiratory dyspnea, cyanosis, and an unproductive cough. Her chest x-rays showed extensive pneumomediastinum (PM), mild subcutaneous emphysema at the right anterior triangle of the neck, and right upper-lobe atelectasis. Her PM resulted from the “Macklin effect,” which involves a three-step process: overly distended alveolar rupture, air dissection along the bronchovascular sheaths, and air spreading into the mediastinum.

Methods

Treatment consisted of oxygen therapy, parenteral corticosteroids, and nebulized bronchodilators.

Results

She made a good recovery, and was discharged from the intensive care unit after 2 days.

Conclusion

This case illustrates that conservative management strategies in this severe and unusual complication of asthma exacerbation can result in rapid and complete recovery. Nonetheless, every asthma exacerbation should be considered potentially life-threatening, and must be treated promptly and adequately.

Section snippets

Case Report

A 17-year-old girl was admitted to our emergency department because of a severe asthma exacerbation. She had developed asthma at age 7 years, and her exacerbations had occurred frequently, usually triggered by exposure to cold air and/or physical activities. Her asthma was classified as not well-controlled.7 Her medical treatment consisted of budesonide/formoterol metered dose inhaler 80 μg/4.5 μg, two inhalations twice daily (dose dependent on severity of asthma), and oral prednisone.

Discussion

Pneumomediastinum can be divided into two groups: SPM without an obvious primary source, and secondary pneumomediastinum with a specific, demonstrable, responsible pathological event such as trauma, intrathoracic infections, esophageal perforation, and others.8

Spontaneous PM is an uncommon clinical entity. In asthmatic patients, this complication is considered rare, with an incidence of 0.2% to 0.3%.9, 10, 11 Its course is usually favorable, with no other complications. The more common

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