1
Pneumomediastinum in student aviators- The Israeli air
force experience
Alon Grossman M.D1, Ayal Romem M.D2, Bella Azaria M.D1, Liav Goldstein M.D2,
Erez BarenboimM.D2
1. The Israeli air force aeromedical center, Tel Hashomer, Israel
2. The Israeli air force surgeon general’s office headquarters, Tel Hashomer,
Israel
Running title: Pneumomediastinum in aviators
Word count in abstract: 159
Word count in manuscript: 1770
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Abstract
Pneumomediastinum (PM) is an uncommon phenomenon, though it is one of the most
common causes of chest pain in young adults. It may be particularly important
among aviators, since it may cause sudden incapacitation. Spontaneous PM is a
variant of pneumomediastinum unrelated to trauma and is frequently related to the
Valsalva maneuver. This maneuver is performed as part of the anti-G straining
maneuver, used during high-performance flight and this may increase the risk of
recurrence. This raises concern regarding the return to flight duties of aviators after
an episode of spontaneous PM. We present 10 student aviators who experienced a
single episode of uncomplicated PM that was unrelated to flight. All were returned to
flying duty, following a normal pulmonary evaluation and are still in active duty.
Follow-up was conducted for a mean period of 74.7 months without any adverse
consequences. These findings support the return of aviators to flying duty after a
single episode of uncomplicated spontaneous PM.
Key words: pneumomediastinum, aerospace medicine, aviators.
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Introduction
Pneumomediastinum (PM) is an uncommon entity, usually related to penetrating or
blunt trauma.
It may also occur in association with situations such as positive
pressure ventilation or esophageal rupture (1). Although the risk of recurrence of this
entity is low, conditions encountered in the aviation environment are thought to
contribute to increased chances of recurrence.
Such a recurrence may lead to
incapacitation, this increasing the fear of this entity. We review the Israeli air force
experience with 10 cases of student aviators who experienced a single episode of PM
and were returned to flying duty following a through evaluation.
Presentation of cases
10 student aviators who experienced episodes of spontaneous PM were identified
between 1977 and 2002 and are presented in table 1. All patients were healthy prior
to the episode, with no evidence of bronchospasm or another obstructive condition.
The clinical presentation was variable and all cases were hospitalized with the
diagnosis confirmed by chest radiography. 9 were treated conservatively and were
discharged after an average of 2 days. A single patient required insertion of a chest
tube due to concomitant pneumothorax and was hospitalized for 7 days. Only two of
the patients experienced concomitant pneumothorax and only one experienced
concomitant pneumoperitoneum; in neither of them underlying lung pathology was
confirmed. The episodes occurred during the students’ training period and were not
associated with flight. In fact, none of the students was involved in flight during the
week prior to the episode.
All patients underwent pulmonologic workup before returning to flight. 8 of them
underwent a computed tomography (CT) scan, 6 of these being high-resolution scans.
One of the episodes occurred in 1977, when CT scans were unavailable.
All
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underwent pulmonary function tests, which were found to be normal in 9 subjects.
One of the subjects had a decreased Forced expiratory volume in 1 second/forced vital
capacity ratio and therefore underwent a bronchial provocation challenge with
metacholine that was found to be normal. Three of the subjects underwent altitude
chamber testing without any pulmonary complaints. Following the episode, all student
aviators were evaluated by a pulmonary specialist and were returned to active flying
duty after an average waiting period of 4 weeks.
Follow-up was conducted for an average period of 74.7 months (range 12- 306
months) during which all remained symptom-free and in active flying duty. 5 of them
are operating high- performance aircraft, 2 operate cargo aircraft and 3 are helicopter
pilots.
Their flight career was unaffected by the previous episode of
pneumomediastinum. Routine follow-up of these patients including annual physical
examination and history taking by a flight surgeon and spirometry revealed no
abnormal findings.
Discussion
The clinical picture of PM is variable, but the most common complaint is one of
stabbing precordial chest pain. Other complaints may include dyspnea, dysphagia and
neck puffiness. Most patients demonstrate crepitations in the neck and in many
patients swelling is apparent in the neck, axillae and chest or abdominal wall (2). The
diagnosis may be suspected on clinical grounds, but should be confirmed by chest
radiographs, which also help rule out pneumothorax. Spontaneous PM is defined as
PM occurring in healthy individuals with no underlying lung pathology and no
antecedent history of trauma. It is particularly common among the young age group.
Spontaneous PM is usually related to a Valsalva maneuver and has been described in
various situations where this maneuver is used, such as labor, seizures and physical
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activity (1,2). The relation between this maneuver and PM is explained by the
Macklin Effect, which involves alveolar ruptures with air dissection along
bronchovascular sheaths to the mediastinum (3).
The incidence of spontaneous
pneumomediastinum in persons aged 14-29 is approximately 1:3000, making it
second only to pnemothorax as a cause of chest pain in this age group (4). This entity
usually requires no intervention unless concomitant pnemothorax is present or in rare
cases of tension PM. The average hospitalization time for patients with uncomplicated
pneumomediastinum is 3.3 days and the only treatment necessary is reassurance.
Recurrence is also extremely uncommon, since in most cases no lung pathology is
present. Yellin and colleagues reported only one recurrence of 16 cases followed up
for 6-52 months (4), whereas Abolnik and colleagues reported 2 cases of recurrence
among 23 patients after an average follow-up of 87.4 months (5).
PM may be associated with pneumothorax.
Pneumothorax associated with
pneumomediastinum evolves in a different fashion from spontaneous pneumothorax.
Spontaneous PM results either from increased intra-alveolar pressure or from
decreased interstitial pressure.
Air then flows from the alveolar space to the
interstitial space. In some cases of spontaneous PM, the increased interstitial pressure
may result in a tear of the parietal pleura leading to the development of secondary
pneumothorax.
This differs from primary spontaneous pneumothorax, which is
caused by tear of subpleural blebs (6).
The US Navy reported 5 cases of spontaneous PM, which represented an incidence of
1:800 among marine recruits during the period between September 1974 and August
1975. They attributed this high incidence to the Marine exercise program, which
includes frequent marching and yelling.
These activities generate high
intrapulmonary pressures that may result in alveolar rupture. This is the only report
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of spontaneous PM among military personnel up to date (7). We reported 10 cases of
student aviators who experienced spontaneous pneumothorax. We cannot report the
actual number of student aviators during this time period, but this phenomenon is
certainly uncommon. Despite the rarity of this entity, we believe that the lack of
previous reports in this issue makes our report crucial. No similar cases were reported
in active duty aviators during this same time period in the Israeli air force and
therefore it seems, that the underlying mechanism responsible for the formation of
PM in our students is similar to that reported in US Navy marine recruits.
Aeromedical concerns
PM may pose a particular risk to aviators because it may cause sudden incapacitation.
Severe pain and dyspnea induced by PM may interfere with the aviator's performance.
In cases of a two-seat aircraft, the risk of sudden incapacitation is low, although these
complaints may lead to premature mission termination.
PM may also lead to secondary pneumothorax. This, as stated earlier, is caused by a
parietal pleural tear secondary to increased interstitial pressure and is not due to
rupture of subpleural blebs.
This secondary pneumothorax may be lethal.
The
recurrence rate for primary spontaneous pneumothorax is much higher than
spontaneous PM, since it is usually caused by underlying lung pathology.
The
probability of a recurrence of spontaneous pneumothorax is approximately 50% after
the first episode, 62% following the second and 80% following the third (8).
Aviators, who experienced spontaneous pneumothorax, should be recommended a
thoracoscopic surgery, both because of the risk of barotrauma and because of the risk
of sudden incapacitation. Following thoracoscopic surgery, aviators may be returned
to flying duty, since the recurrence rate following this procedure is extremely low,
ranging from 0 to 1.6% (9-11). Since the recurrence rate of spontaneous PM is similar
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to that of treated pneumothorax we believe patients may be returned to flying duty
following a single episode of spontaneous PM. Yet, because of the dreaded potential
for incapacitation due to PM recurrence, we believe that lung evaluation should be
conducted in all patients, in order to rule out lung pathology. This should include
examination by a pulmonary specialist, performance of a high resolution CT scan to
rule out the presence of bulla and pulmonary function testing to rule out
hyperinflation due to obstructive lung disease. We believe that a waiting period of at
least 2 weeks is prudent prior to the return of these aviators to flying duty to ensure
complete air absorption even in the presence of a completely normal work-up.
In our series, only 2 aviators experienced an episode of concomitant pneumothorax.
One of them underwent pulmonary function testing and hypobaric chamber testing
before his return to active duty. He did not undergo a CT examination due to the fact
that his symptoms developed in 1977, when CT was not available in Israel. The other
underwent a high-resolution CT examination and pulmonary function testing that
were found to be normal.
Aviators frequently make use of the Valsalva maneuver, particularly in high
performance aircraft. Since PM is usually related to this maneuver, its incidence may
be increased, particularly in subjects who experienced a former episode. Flight at
high altitudes may cause lung hyperinflation and contribute to the formation of PM as
well. Decompression may cause decreased interstitial pressure and contribute to the
formation of PM.
All these factors might, theoretically, increase the chance of
recurrence of PM among aviators, but this has not been tested previously. Our small
sample revealed no recurrences.
In our series, 10 aviators with a history of PM were followed for an average of 74.7
months with no evidence of recurrence or pulmonary complaints. 5 of these aviators
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serve as helicopter or cargo pilots, where the Valsalva maneuver is rarely used and
where there always is a second crewmember that can operate the aircraft in cases of
sudden incapacitation. The other 5 serve as high performance aviators and thus are
potentially at a higher risk of recurrence. A through evaluation was performed in all
student aviators to rule out underlying lung pathology, specifically subpleural blebs.
Once this has been ruled out, they were returned to unlimited flying status, their flying
career being unaffected.
Conclusions
PM is a self-limited condition with a very low recurrence rate. Therefore, we believe
that aviators may be returned to flying duty after a single episode of spontaneous PM.
Despite the hypothetical increased risk of recurrence among high performance
aviators, our follow-up showed no recurrences. Even though the incidence of lung
pathology among patients with spontaneous PM is extremely low, we believe that all
should undergo evaluation by a lung specialist and perform pulmonary function
testing and high-resolution CT to rule a rare but potentially lethal underlying lung
disease. A waiting period of at least 2 weeks should be recommended before return
to flying duty in uncomplicated cases.
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Table 1: patient characteristics and clinical course
Time to
Length of
#
Clinical
Additional imaging
Pulmonary
Age
return to
hospitalization
presentation
studies
function tests
flight
(days)
(weeks)
Chest pain
N (DLCO
1
20
and
HRCT- normal
4
6
1
5
normal)
dysphagia
Chest pain
N (DLCO
2
23
and
HRCT-normal
normal)
dyspnea
3
23
4
20
Dyspnea
HRCT- normal
N
1
8
Not performed
N
1
2
1
2
Chest
tightness
N (DLCO
5
19
Dyspnea
HRCT-normal
normal)
6
20
Dyspnea
HRCT-normal
N
3
4
7
22
Dyspnea
CT- normal
N
1
6
8
19
Dyspnea
HRCT- normal
1
6
7
2
1
5
N (DLCO
normal)
9
19
Chest pain
Chest X-ray
N
Decrease in
10
19
Chest pain
CT-small
FEV1/FVC
and
opacifications at
Normal
dyspnea
the left lung apex
provocation
test
HRCT- high resolution computed tomography, N-normal, DLCO- diffusion
capacity, FEV1- forced expiratory volume in 1 second. FVC- forced vital capacity.
10
12. Voge VM, Anthracite R.
Spontaneous pneumothorax in the USAF aircrew
population: a retrospective study. Aviat Space Environ Med 1986; 57:939-49.