今日の臨床サポート

縦隔気腫

著者: 山本 洋 信州大学医学部内科学第一教室

監修: 久保惠嗣 信州大学名誉教授・地方独立行政法人 長野県立病院機構理事長

著者校正/監修レビュー済:2021/11/10
患者向け説明資料

概要・推奨   

  1. 若年でやせ型の男性の胸痛では、特発性縦隔気腫を鑑別診断に挙げることを勧める(推奨度2)
  1. 縦隔気腫の誘因となるようなエピソードの後や原因となるような疾患をもつ症例で、胸痛や息切れ・呼吸困難などの症状がみられた場合には縦隔気腫を鑑別に挙げることを勧める(推奨度2)
  1. 胸部X線写真(CXR)で検出しきれない特発性縦隔気腫が少なからずあるため、CXRが正常範囲と判断されても、特発性縦隔気腫が疑われる場合は積極的に胸部CTを撮影することを勧める(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
山本 洋 : 特に申告事項無し[2021年]
監修:久保惠嗣 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行って一部を改訂し、ガイドラインをアップデートした。
  1. 新型コロナウイルス感染症(COVID-19)関連の記載を追記した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 縦隔気腫は縦隔内に空気が貯留した状態と定義される。明らかな原因がなく生じる特発性縦隔気腫と、外傷や何らかの病的状態が原因で生じる続発性縦隔気腫に分類される。
  1. 特発性縦隔気腫は若年でやせ型の男性に好発し、その発症頻度は3~4万人に1人程度とされている。胸痛、呼吸困難感などを呈し、一般に予後は良好だが、急速に増悪する症例もあるため慎重な経過観察が必要である。
  1. 続発性縦隔気腫は基礎疾患に合併するため多くは予後不良であり、縦隔気腫の管理に加えて基礎疾患に対する治療が重要である。<図表>
問診、診察のポイント  
  1. 特発性縦隔気腫の好発背景に関して確認する。

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文献 

著者: T Kaneki, K Kubo, A Kawashima, T Koizumi, M Sekiguchi, S Sone
雑誌名: Respiration. 2000;67(4):408-11. doi: 29539.
Abstract/Text BACKGROUND: Spontaneous pneumomediastinum (SPM) usually occurs in young people without an apparent precipitating factor or disease. Although there have been many studies focused on the clinical features and standard chest X-ray (CXR) findings of SPM, few have reviewed the chest computed-tomographic (CT) findings.
OBJECTIVES: We assessed SPM using CXR and CT, and the relation between them.
METHODS: We evaluated 33 patients (26 males) diagnosed with SPM on the basis of symptoms and chest radiological findings.
RESULTS: Three patients showed normal CXR but a diagnostic CT scan. Seven showed mild pneumomediastinum on CXR. In these 10 patients, pneumomediastinum was easily detected by chest CT. Moderate and severe SPM were easily detected by both CXR and CT.
CONCLUSIONS: These findings suggested that CXR alone poorly detected approximately 30% of SPM and that chest CT scan was needed to make the diagnosis in these cases. It seems likely that SPM is underdiagnosed by 30% or more in clinical practice.

Copyright 2000 S. Karger AG, Basel
PMID 10940795  Respiration. 2000;67(4):408-11. doi: 29539.
著者: Kazuto Takada, Shuuichi Matsumoto, Tetsuo Hiramatsu, Eiji Kojima, Hiroaki Watanabe, Masato Sizu, Shoutarou Okachi, Kiyoko Ninomiya
雑誌名: Respir Med. 2008 Sep;102(9):1329-34. doi: 10.1016/j.rmed.2008.03.023. Epub 2008 Jun 26.
Abstract/Text STUDY OBJECTIVES: Spontaneous pneumomediastinum (SPM) is a rare disorder that usually occurs in young individuals and has a self-limiting course and no recurrence in most cases. But actually in many cases, patients are undergo some examinations or some limitations. The purpose of this study was to evaluate the clinical characteristics and recommend appropriate management of SPM.
DESIGN: Retrospective research of clinical records of a single institution.
RESULTS: Over 11 years, we diagnosed 25 patients (18 males) with SPM. Their average age was 20.1 years (range 13-28 years). Chest pain or neck symptoms were most frequent, and 17 patients (68%) had subcutaneous emphysema. In all cases, blood counts and C-reactive protein (CRP) were measured, and their mean values were 10,100+/-4600/mm(3) and 1.0+/-1.5 mg/dL, respectively. In 20 patients (80%), either leucocytosis or elevated CRP was observed. Twenty-four patients (96%) were admitted (average 7.8+/-4.1 days) and 20 of them were prescribed antibiotics or limited oral intake. The symptoms were self-limiting in all cases and disappeared on average 1.8+/-0.9 days after diagnosis. No recurrence was noted in the approximately 2 years follow-up period.
CONCLUSION: SPM is a self-limiting disease with mild inflammatory signs. For patients suspicious of SPM, shortened hospitalization for about 2 days with observation alone may be feasible, if their symptoms improve gradually. Otherwise, less invasive procedures, such as esophagram, should be performed immediately. Long-term follow-up is usually unnecessary. We propose a new algorithm for management of SPM based on clinical experience.

PMID 18585025  Respir Med. 2008 Sep;102(9):1329-34. doi: 10.1016/j.rme・・・
著者: Manuel Caceres, Syed Z Ali, Rebecca Braud, Darryl Weiman, H Edward Garrett
雑誌名: Ann Thorac Surg. 2008 Sep;86(3):962-6. doi: 10.1016/j.athoracsur.2008.04.067.
Abstract/Text BACKGROUND: Spontaneous pneumomediastinum (SPM) is an unusual occurrence with few cases reported. It is seen after intrathoracic pressure changes leading to alveolar rupture and dissection of air along the tracheobronchial tree. This study was undertaken to provide a thorough clinical and radiologic analysis of this patient population.
METHODS: A retrospective comparative analysis was performed on patients with SPM over 12 years. Patient demographics, clinical presentation, and radiographic and diagnostic studies were recorded. A clinical and radiologic comparison was performed with secondary pneumomediastinum.
RESULTS: Seventy-four patients were identified with a diagnosis of pneumomediastinum. A total of 28 patients with SPM were identified. The major initial complaints were chest pain (54%), shortness of breath (39%), and subcutaneous emphysema (32%). The main triggering events were emesis (36%) and asthma flare-ups (21%). No apparent triggering event was noted in 21% of patients. Chest radiograph was diagnostic in 69%; computed tomography was required in 31%. Esophagram, esophagoscopy, and bronchoscopy were performed on an individual basis and were invariably negative. When compared with secondary pneumomediastinum, SPM is more likely to be discovered by chest radiography, has a lower incidence of pneumothorax and pleural effusion, requires a shorter hospital stay, and has no associated mortality.
CONCLUSIONS: Spontaneous pneumomediastinum is a benign condition that often presents with chest pain or dyspnea. It can develop without a triggering event and with no findings on chest radiography. Treatment is expectant and recurrence is low. Secondary causes must be ruled out to avoid an unfavorable outcome.

PMID 18721592  Ann Thorac Surg. 2008 Sep;86(3):962-6. doi: 10.1016/j.a・・・
著者: Daniel H L Lemmers, Mohammed Abu Hilal, Claudio Bnà, Chiara Prezioso, Erika Cavallo, Niccolò Nencini, Serena Crisci, Federica Fusina, Giuseppe Natalini
雑誌名: ERJ Open Res. 2020 Oct;6(4). doi: 10.1183/23120541.00385-2020. Epub 2020 Nov 16.
Abstract/Text Background: In mechanically ventilated acute respiratory distress syndrome (ARDS) patients infected with the novel coronavirus disease (COVID-19), we frequently recognised the development of pneumomediastinum and/or subcutaneous emphysema despite employing a protective mechanical ventilation strategy. The purpose of this study was to determine if the incidence of pneumomediastinum/subcutaneous emphysema in COVID-19 patients was higher than in ARDS patients without COVID-19 and if this difference could be attributed to barotrauma or to lung frailty.
Methods: We identified both a cohort of patients with ARDS and COVID-19 (CoV-ARDS), and a cohort of patients with ARDS from other causes (noCoV-ARDS).Patients with CoV-ARDS were admitted to an intensive care unit (ICU) during the COVID-19 pandemic and had microbiologically confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. NoCoV-ARDS was identified by an ARDS diagnosis in the 5 years before the COVID-19 pandemic period.
Results: Pneumomediastinum/subcutaneous emphysema occurred in 23 out of 169 (13.6%) patients with CoV-ARDS and in three out of 163 (1.9%) patients with noCoV-ARDS (p<0.001). Mortality was 56.5% in CoV-ARDS patients with pneumomediastinum/subcutaneous emphysema and 50% in patients without pneumomediastinum (p=0.46).CoV-ARDS patients had a high incidence of pneumomediastinum/subcutaneous emphysema despite the use of low tidal volume (5.9±0.8 mL·kg-1 ideal body weight) and low airway pressure (plateau pressure 23±4 cmH2O).
Conclusions: We observed a seven-fold increase in pneumomediastinum/subcutaneous emphysema in CoV-ARDS. An increased lung frailty in CoV-ARDS could explain this finding more than barotrauma, which, according to its etymology, refers to high transpulmonary pressure.

Copyright ©ERS 2020.
PMID 33257914  ERJ Open Res. 2020 Oct;6(4). doi: 10.1183/23120541.0038・・・
著者: B Levin
雑誌名: Clin Radiol. 1973 Jul;24(3):337-8.
Abstract/Text
PMID 4730225  Clin Radiol. 1973 Jul;24(3):337-8.
著者: G L Duehring
雑誌名: Radiol Technol. 2000 Sep-Oct;72(1):51-5.
Abstract/Text Boerhaave syndrome is a serious and rapidly fatal spontaneous esophageal rupture that mimics myocardial infarction or upper gastrointestinal conditions. Initially misdiagnosed about 50% of the time, Boerhaave syndrome has a mortality rate of more than 90% without prompt diagnosis and treatment. This article presents a case of nearly fatal Boerhaave syndrome in an otherwise healthy young adult and discusses the historical, statistical, pathophysiological, diagnostic and therapeutic aspects of the disease.

PMID 11019407  Radiol Technol. 2000 Sep-Oct;72(1):51-5.
著者: M R Bladergroen, J E Lowe, R W Postlethwait
雑誌名: Ann Thorac Surg. 1986 Sep;42(3):235-9.
Abstract/Text Over the past 47 years (1937 to 1984), a total of 127 patients with esophageal perforation or rupture were evaluated at Duke Medical Center or the Durham Veterans Administration Medical Center. In 13 patients, the diagnosis was established at the time of autopsy and in the remaining 114, the diagnosis was established clinically. The etiology, radiological findings, underlying esophageal disease, time interval between onset of symptoms and therapy, and eventual outcome were evaluated. Patients with anastomotic leaks and those in whom carcinoma resulted in perforation or fistula were excluded. Iatrogenic causes were responsible for 55% of perforations, followed by spontaneous rupture in 15%, foreign body perforation in 14%, and traumatic perforation in 10%. Of the 127 patients, 114 underwent treatment involving primary closure (43%), drainage alone (28%), resection (9%), or nonoperative therapy (20%). The overall mortality among these 114 patients was 21%. Fourteen patients sustained a major complication requiring additional operative intervention. The overall mortality among patients requiring reoperation was 57%. Survival was significantly influenced by a delay in treatment of greater than 24 hours. With the exception of nonoperative therapy, survival was improved for all forms of treatment instituted within 24 hours. Primary closure within 24 hours resulted in the most favorable outcome (92% survival). In addition to early treatment, other factors associated with a favorable outcome included traumatic perforation (100% survival), foreign-body perforations (94% survival), and iatrogenic causes (80% survival). Spontaneous rupture resulted in the lowest survival (37%). The incidence of esophageal perforation has increased dramatically since 1967.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 3753071  Ann Thorac Surg. 1986 Sep;42(3):235-9.
著者: Atilla Eroglu, Ibrahim Can Kürkçüogu, Nurettin Karaoganogu, Celal Tekinbaş, Omer Yimaz, Mahmut Başog
雑誌名: Dis Esophagus. 2004;17(1):91-4. doi: 10.1111/j.1442-2050.2004.00382.x.
Abstract/Text Esophageal perforation is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. We performed a retrospective clinical review of 36 patients, 15 women (41.7%) and 21 men (58.3%), treated at our hospital for esophageal perforation between 1989 and 2002. The mean age was 54.3 years (range 7-76 years). Iatrogenic causes were found in 63.9% of perforations, foreign body perforation in 16.7%, traumatic perforation in 13.9% and spontaneous rupture in 5.5%. Perforation occurred in the cervical esophagus in 12 cases, thoracic esophagus in 13 and abdominal esophagus in 11. Pain was the most common presenting symptom, occurring in 24 patients (66.7%). Dyspnea was noted in 14 patients (38.9%), fever in 12 (33.3%) and subcutaneous emphysema in 25 (69.4%). Management of esophageal perforation included primary closure in 19 (52.8%), resection in seven (19.4%) and non-surgical therapy in 10 (27.8%). The 30-day mortality was found to be 13.9%, and mean hospital stay was 24.4 days. In the surgically treated group the mortality rate was three of 26 patients (11.5%), and two of 10 patients (20%) in the conservatively managed group. Survival was significantly influenced by a delay of more than 24 h in the initiation of treatment. Primary closure within 24 h resulted in the most favorable outcome. Esophageal perforation is a life threatening condition, and any delay in diagnosis and therapy remains a major contributor to the attendant mortality.

Copyright 2004 ISDE
PMID 15209749  Dis Esophagus. 2004;17(1):91-4. doi: 10.1111/j.1442-205・・・
著者: J W Pate, W A Walker, F H Cole, E W Owen, W H Johnson
雑誌名: Ann Thorac Surg. 1989 May;47(5):689-92.
Abstract/Text This retrospective review of 34 patients with spontaneous rupture of the esophagus, which spans a 30-year period, attempts to identify areas in diagnosis and therapy that might alter the dismal prognosis. The diagnosis and definitive surgical repair of Boerhaave's syndrome were frequently delayed. Delay resulted in a significant increase in complication rates. Pain (85%) and vomiting (71%) were the only common historical events suggesting the diagnosis. Physical examination was of aid in the diagnosis in only the 9 patients (27%) who demonstrated cervical or mediastinal emphysema. The initial chest roentgenogram was abnormal in 97% of the patients, but was interpreted as "compatible with perforation of the esophagus" in only 27%. Esophagography was diagnostic in 23 of 24 patients in whom it was used. Thoracentesis was of little diagnostic aid, but pleural fluid pH was measured in only 15% of the patients. Prompt surgical repair, regardless of time after onset, appears to be the indicated therapy.

PMID 2730190  Ann Thorac Surg. 1989 May;47(5):689-92.
著者: S Attar, J R Hankins, C M Suter, T R Coughlin, A Sequeira, J S McLaughlin
雑誌名: Ann Thorac Surg. 1990 Jul;50(1):45-9; discussion 50-1.
Abstract/Text The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.

PMID 2369229  Ann Thorac Surg. 1990 Jul;50(1):45-9; discussion 50-1.
著者: J P de Schipper, A F Pull ter Gunne, H J M Oostvogel, C J H M van Laarhoven
雑誌名: Dig Surg. 2009;26(1):1-6. doi: 10.1159/000191283. Epub 2009 Jan 15.
Abstract/Text OBJECTIVE: Boerhaave's syndrome is a spontaneous rupture of the oesophagus with a lack of diagnostic and treatment consistency in the literature. Therefore, we reviewed all published literature in order to design a treatment algorithm based on the literature.
STUDY DESIGN: A systematic literature review written in the English language since 1975.
RESULTS: We reviewed all known literature. Treatment of the Boerhaave syndrome was divided into three categories: conservative, endoscopic and surgical approach. The survival rate of all treatments was 75, 100 and 81%, respectively.
CONCLUSION: Boerhaave's syndrome should be treated endoscopically when diagnosed within 48 h and when there are no signs of sepsis. However, when a patient is diagnosed within 48 h and has a septic profile, thoracotomy with hemifundoplication and pleural/mediastinal drainage should be performed; and in case of intra-abdominal leakage, a laparotomy for local repair should be performed. When a patient is diagnosed after 48 h, conservative treatment should be followed and only when a patient gets a septic profile is surgical treatment indicated.

Copyright (c) 2009 S. Karger AG, Basel.
PMID 19145081  Dig Surg. 2009;26(1):1-6. doi: 10.1159/000191283. Epub ・・・
著者: George J Koullias, Dimitris P Korkolis, Xu Jie Wang, Graeme L Hammond
雑誌名: Eur J Cardiothorac Surg. 2004 May;25(5):852-5. doi: 10.1016/j.ejcts.2004.01.042.
Abstract/Text OBJECTIVES: Spontaneous pneumomediastinum (SPM) is an uncommon, benign, self-limited disorder that usually occurs in young adults without any apparent precipitating factor or disease. The purpose of this study was to review our experience in dealing with this entity and detail a reasonable course of assessment and management.
METHODS: A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated in a single institution between 1993 and 2000.
RESULTS: Twenty-four patients were identified who included 18 men and 6 women with a mean age of 17.5 years. Acute onset chest pain was the predominant symptom at presentation. Only half of the patients developed clinically evident subcutaneous emphysema. The most frequent precipitating factor was a history of illegal drug abuse seen in 25% of patients. Other factors included asthmatic bronchospasm, physical activity and violent coughing or vomiting. Chest radiography and computerized tomography (CT) were diagnostic in all cases with CT scan revealing six cases with associated pulmonary abnormalities. Esophagogram and flexible bronchoscopy were selectively used. Twelve patients (50%) were admitted to the hospital. Their mean hospital stay was 2 days. All patients were conservatively treated. In a follow-up of 3-10 years no complications or recurrences were observed.
CONCLUSIONS: SPM follows alveolar rupture in the pulmonary interstitium. It shows a rising incidence in young drug users. It has a wide range of clinical features necessitating a high index of suspicion. Chest X-ray and CT scan should be always performed. Hospitalization and aggressive approach should be limited. SPM responds well to conservative treatment and follows a benign natural course.

PMID 15082293  Eur J Cardiothorac Surg. 2004 May;25(5):852-5. doi: 10.・・・
著者: Faisal Al-Mufarrej, Jehangir Badar, Farid Gharagozloo, Barbara Tempesta, Eric Strother, Marc Margolis
雑誌名: J Cardiothorac Surg. 2008 Nov 3;3:59. doi: 10.1186/1749-8090-3-59. Epub 2008 Nov 3.
Abstract/Text OBJECTIVES: The objective of this case series is to review our experience with spontaneous pneumomediastinum, review the available literature, and refine the current clinical approach to this uncommon condition.
METHODS: The case notes of all patients admitted to the George Washington University Medical Center with spontaneous pneumomediastinum from April 2005 to June 2008 were retrospectively reviewed, indentifying seventeen patients on whom various data was collected and analyzed.
RESULTS: The typical patient is a young man. The commonest presenting complaint is chest pain. Odynophagia and subcutaneous emphysema are common. Leucocytosis is uncommon. The need for swallow studies, antibiotics, and prolonged hospitalization is uncommon. Most patients have no recurrences or sequelae on long-term follow-up.
CONCLUSION: Spontaneous pneumomediastinum is an uncommon, self-limiting condition. Due to concerns for the integrity of the aero-digestive tract, the finding of spontaneous pneumomediastinum usually results in unnecessary radiological investigations, dietary restriction and antibiotic administration with prolonged hospitalization.

PMID 18980688  J Cardiothorac Surg. 2008 Nov 3;3:59. doi: 10.1186/1749・・・
著者: Andrew Rhodes, Laura E Evans, Waleed Alhazzani, Mitchell M Levy, Massimo Antonelli, Ricard Ferrer, Anand Kumar, Jonathan E Sevransky, Charles L Sprung, Mark E Nunnally, Bram Rochwerg, Gordon D Rubenfeld, Derek C Angus, Djillali Annane, Richard J Beale, Geoffrey J Bellinghan, Gordon R Bernard, Jean-Daniel Chiche, Craig Coopersmith, Daniel P De Backer, Craig J French, Seitaro Fujishima, Herwig Gerlach, Jorge Luis Hidalgo, Steven M Hollenberg, Alan E Jones, Dilip R Karnad, Ruth M Kleinpell, Younsuk Koh, Thiago Costa Lisboa, Flavia R Machado, John J Marini, John C Marshall, John E Mazuski, Lauralyn A McIntyre, Anthony S McLean, Sangeeta Mehta, Rui P Moreno, John Myburgh, Paolo Navalesi, Osamu Nishida, Tiffany M Osborn, Anders Perner, Colleen M Plunkett, Marco Ranieri, Christa A Schorr, Maureen A Seckel, Christopher W Seymour, Lisa Shieh, Khalid A Shukri, Steven Q Simpson, Mervyn Singer, B Taylor Thompson, Sean R Townsend, Thomas Van der Poll, Jean-Louis Vincent, W Joost Wiersinga, Janice L Zimmerman, R Phillip Dellinger
雑誌名: Intensive Care Med. 2017 Mar;43(3):304-377. doi: 10.1007/s00134-017-4683-6. Epub 2017 Jan 18.
Abstract/Text OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012".
DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.
METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.
RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.
CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

PMID 28101605  Intensive Care Med. 2017 Mar;43(3):304-377. doi: 10.100・・・
著者: Vivek N Iyer, Avni Y Joshi, Jay H Ryu
雑誌名: Mayo Clin Proc. 2009 May;84(5):417-21. doi: 10.1016/S0025-6196(11)60560-0.
Abstract/Text OBJECTIVE: To clarify the clinical presentation and course of patients with spontaneous pneumomediastinum (SP) and to determine the usefulness of diagnostic testing in these patients.
PATIENTS AND METHODS: We conducted a retrospective review of 62 consecutive adult patients (age >or=18 years) diagnosed as having SP during an 11-year period from July 1, 1997, to June 30, 2008. The study cohort included 41 men and 21 women (median age, 30 years; interquartile range, 20-69 years).
RESULTS: Among the 62 study patients, the most common presenting symptoms were chest pain (39 patients [63%]), cough (28 [45%]), and dyspnea (27 [44%]). Preexisting lung diseases were identified in 27 patients (44%) and included interstitial lung disease, asthma, lung malignancies, bronchiolitis obliterans syndrome, chronic obstructive pulmonary disease, bronchiectasis, and cystic lung lesions. The initial diagnosis of SP was achieved by chest radiography in 52 patients (84%); the remaining cases were diagnosed by computed tomography. Forty-seven patients (76%) were hospitalized for a median duration of 2.5 days. Additional diagnostic procedures were performed in 27 patients (44%) and included contrast esophagography, bronchoscopy, and esophagogastroduodenoscopy; however, they did not yield a pathologic cause in any patient. Pneumothorax was identified in 20 patients (32%), but less than one-third of these patients underwent chest tube thoracostomy. No episodes of mediastinitis or sepsis occurred. Recurrence of SP was seen in 1 patient, and thoracoscopic surgery was performed in 1 patient for persistent air leak (pneumothorax).
CONCLUSION: Spontaneous pneumomediastinum was associated with a relatively benign clinical course; however, pneumothorax was seen in 32% of cases. Diagnostic testing to determine a pathologic cause yielded little clinically relevant information in these patients.

PMID 19411438  Mayo Clin Proc. 2009 May;84(5):417-21. doi: 10.1016/S00・・・
著者: Sabine Elisabeth Gabor, Heiko Renner, Alfred Maier, Freyja Maria Smolle Jüttner
雑誌名: Eur J Cardiothorac Surg. 2005 Sep;28(3):502-3. doi: 10.1016/j.ejcts.2005.05.015.
Abstract/Text A 21-year-old female with chronic membranoproliferative nephritis was admitted for suspected esophageal disruption and asthma after severe, prolonged vomiting. At the time of admission she presented with dyspnea, tachypnea, arterial hypotension and tachycardia. Physical examination showed discrete signs of ectopic air at the neck and distended cervical veins. CT-scan of the chest showed severe mediastinal emphysema with compression of the right atrium. After cervical mediastinotomy the cardiorespiratory parameters normalized immediately. Esophagoscopy showed multiple longitudinal mucosal tears between 25 and 45 cm; fluoroscopically, there was no leakage of contrast medium. Following conservative treatment the patient recovered completely and was discharged on day 8.

PMID 16046264  Eur J Cardiothorac Surg. 2005 Sep;28(3):502-3. doi: 10.・・・
著者: Christian Powell, Brian Kendall, Richard Wernick, John E Heffner
雑誌名: Chest. 2007 Nov;132(5):1710-3. doi: 10.1378/chest.07-0286.
Abstract/Text
PMID 17998377  Chest. 2007 Nov;132(5):1710-3. doi: 10.1378/chest.07-02・・・
著者: J Nounla, R b Tröbs, J Bennek, I Lotz
雑誌名: J Pediatr Surg. 2004 Jan;39(1):E23-4.
Abstract/Text Spontaneous pneumomediastinum (SPM) occurs rarely in children. The diagnosis is based on physical examination and chest radiography. Conservative therapy usually leads to recovery. However, SPM in association with severe hypoxia, tachycardia, metabolic acidosis, and high ventilation pressures indicates clinically significant tension in the mediastinum. A collar mediastinotomy is the treatment of choice in these circumstances.

PMID 14694402  J Pediatr Surg. 2004 Jan;39(1):E23-4.
著者: I Abolnik, I S Lossos, R Breuer
雑誌名: Chest. 1991 Jul;100(1):93-5.
Abstract/Text Spontaneous pneumomediastinum (SPM) is a relatively uncommon, infrequently reported entity. To determine the clinical presentation and sequelae of SPM, data were obtained from 25 patients: 14 from Hadassah University Hospital, and 11 from other medical institutions. The mean age was 18.8 +/- 5.2 years (+/- SD), with a range of 8 to 31 years. The most common presenting complaint was retrosternal pain in 22 patients (88 percent), dyspnea in 15 (60 percent), dysphagia in 10 (40 percent), and weakness in 10 (40 percent). Predisposing factors for the development of SPM could be identified in 18 patients (72 percent). Information on the sequelae of SPM during a mean period of 87.4 +/- 38.0 months following the initial SPM episode was obtained from 23 patients. Recurrent SPM occurred in 1 patient at 18 months, and another patient experienced 4 episodes of recurrent spontaneous pneumothorax. No other long-term sequelae were reported. We conclude that SPM is a benign self-limited disease with diverse clinical manifestations. Although uncommon, recurrences of SPM may be observed.

PMID 1824034  Chest. 1991 Jul;100(1):93-5.
著者: Baldassare Mondello, Rosaria Pavia, Paolo Ruggeri, Mario Barone, Pietro Barresi, Maurizio Monaco
雑誌名: Lung. 2007 Jan-Feb;185(1):9-14. doi: 10.1007/s00408-006-0002-7. Epub 2007 Feb 15.
Abstract/Text Spontaneous pneumomediastinum (SPM) is defined as the presence of air in the mediastinum, developing in the absence of traumatic, iatrogenic, or preceding pulmonary pathologies (emphysema, chronic bronchitis, and lung cancer). The aim of this study was to review our experiences with SPM, underlining its symptomatology, diagnosis, treatment, and followup, and defining a reasonable course of assessment and management. A retrospective case series was conducted to identify adult patients with SPM who were diagnosed and treated in our institution between 1998 and 2005. Eighteen patients (10 males) were identified (average age = 25 +/- 4.8 years). Acute onset of chest pain was the predominant symptom at presentation. All patients developed clinically evident subcutaneous emphysema and underwent chest computerized tomography. Fiber bronchoscopy and echocardiogram were used selectively (8 patients). The average hospital stay was 6 (+/-1.4) days. Sixteen patients were conservatively treated, and only two patients were treated with thoracic drainage due to a related pneumothorax. The disease followed a benign evolution in all patients and, as of today, no relapse has been reported. SPM is an uncommon pathology with a usually benign course. The authors discuss SPM. A diagnostic algorithmic approach is necessary to rule out severe secondary entities and consequences that need urgent treatment.

PMID 17310299  Lung. 2007 Jan-Feb;185(1):9-14. doi: 10.1007/s00408-006・・・
著者: William D Brearley, Lee Taylor, Michael W Haley, Laszlo Littmann
雑誌名: Int J Cardiol. 2007 Apr 25;117(2):e73-5. doi: 10.1016/j.ijcard.2006.11.156. Epub 2007 Feb 22.
Abstract/Text Pneumomediastinum is characterized by dissecting air within the connective tissues supporting the mediastinum. This condition has been associated with multiple electrocardiographic abnormalities including T-wave inversion, electrical alternans, loss of R wave progression, and low voltage QRS. We describe a case of pneumomediastinum with electrocardiographic changes mimicking acute ST-segment elevation myocardial infarction. Laboratory studies and echocardiography demonstrated no evidence of myocardial injury, and the electrocardiographic abnormality promptly resolved with resolution of the pneumomediastinum. The apparent ST-segment elevation appeared to be the result of electrocardiographic artifact, possibly related to epidermal stretch synchronous with the cardiac cycles.

PMID 17320223  Int J Cardiol. 2007 Apr 25;117(2):e73-5. doi: 10.1016/j・・・

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