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Mediastinum Intubation and Decompression Technique for Management of Tension Pneumomediastinum

Wednesday, January 3, 2024

Gilbert S. Mediastinum Intubation and Decompression Technique for Management of Tension Pneumomediastinum. January 2024. doi:10.25373/ctsnet.24938568

Tension pneumomediastinum is one of the life-threatening complications of COVID-19 (coronavirus disease 2019). The patient in this video is a sixty-six-year-old man with complaints of cough and high-grade fever for a week prior. He had systemic hypertension and type II diabetes mellitus. He tested positive for COVID-19 on a rapid PCR test. His high resolution computed tomography (HRCT) severity score was 14/25. He was diagnosed with viral pneumonitis and acute respiratory failure.

The patient then suddenly started to develop large subcutaneous emphysema involving the face, neck, chest, and abdomen, extending all the way to both knee joints. He also developed sudden hypotension, requiring ionotropic support. As the patient's oxygen saturation (SPO2) worsened on noninvasive ventilation, he was intubated and given mechanical ventilation support with volume control mode, a fraction of inspired oxygen (FIO2) of 100 percent, and positive end expiratory pressure (PEEP) of 5 cm H2O. His SPO2 was 82 percent. 

HRCT revealed extensive pneumomediastinum with a thick layer of air above the pericardium. Tension pneumomediastinum was suspected. The patient underwent emergency mediastinum intubation and decompression using the mediastinum intubation and decompression (MID) technique. Immediately after the procedure, the patient’s blood pressure and saturation improved. Subcutaneous emphysema reduced significantly within 24 hours. Chest X-rays and HRCT were done to document the resolution of air in the mediastinum. The lung compliance pressures improved and allowed for effective tidal volume delivery.


  1. Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. Journal of the Intensive Care Society. 2017;18(1):52-56. doi:10.1177/1751143716662665


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To avoid potential caval-innominate venous injuries using central cervical dissection during mediastinal intubation and decompression , percutaneous subxyphoid approach under local anesthesia with MAC sedation is safer to perform, as often done for substernal dissection in pericardiocentesis and/or pericardial window with or without real-time sonography. Moreover, crowding the neck with cannula, exposing possible inflammatory and infective reactions, and covering dressings limit central venous access if and when required for intravenous access for long term intravenous administration of fluid, medications, and access for temporary renal dialysis.
Dear Albert Olivier, Greetings. Thankyou for the thoughtful comment. Subxiphoid decompression technique can also be done. I did it in a patient who required MID(mediastinum intubation decompression) for a longer period as his cervical tube was blocked. Another approach to the mediastinum is through dissection in the left second intercostal space parasternal area . In either techniques safety of the patient and familiarity with the approach is the priority. Thank you

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