Letter to the Editor
Risky diving
C. Cascais-Costa
, G. Teixeira, L. Andrade
Corresponding author
Pulmonology Department, Centro Hospitalar Baixo Vouga – Hospital Infante D. Pedro, Aveiro, Portugal
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Santos" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Maria Inês" "apellidos" => "Matias" ] 1 => array:2 [ "nombre" => "Daniela Soares" "apellidos" => "Santos" ] 2 => array:2 [ "nombre" => "Maria Teresa" "apellidos" => "Dias" ] 3 => array:2 [ "nombre" => "Patrícia" "apellidos" => "Carvalho" ] 4 => array:2 [ "nombre" => "Arsénio" "apellidos" => "Santos" ] 5 => array:2 [ "nombre" => "Rui M." "apellidos" => "Santos" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043719301746?idApp=UINPBA00004E" "url" => "/25310437/0000002600000003/v1_202005111106/S2531043719301746/v1_202005111106/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2531043719302041" "issn" => "25310437" "doi" => "10.1016/j.pulmoe.2019.10.002" "estado" => "S300" "fechaPublicacion" => "2020-05-01" "aid" => "1417" "copyright" => "Sociedade Portuguesa de Pneumologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Pulmonol. 2020;26:172-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 240 "formatos" => array:3 [ "EPUB" => 32 "HTML" => 127 "PDF" => 81 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Lung transplant complicated with unexpected neoplasm in explanted lungs: A difficult challenge to manage" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "172" "paginaFinal" => "174" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 532 "Ancho" => 1255 "Tamanyo" => 89939 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pre-transplant computed tomography of the chest in lung window showing a diffuse change in the pulmonary architecture with multiples cists, some of them confluent with thin walls (large arrows) in relation with Langerhans cell histiocytosis. It is also described a septal thickening due to confluence of fibrotic areas with formation of some nodules (thin arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S.C. Silva, N. Murinello, S. Alfarroba, A.S. Santos, P. Calvinho, L. Semedo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "S.C." "apellidos" => "Silva" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Murinello" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Alfarroba" ] 3 => array:2 [ "nombre" => "A.S." "apellidos" => "Santos" ] 4 => array:2 [ "nombre" => "P." "apellidos" => "Calvinho" ] 5 => array:2 [ "nombre" => "L." "apellidos" => "Semedo" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043719302041?idApp=UINPBA00004E" "url" => "/25310437/0000002600000003/v1_202005111106/S2531043719302041/v1_202005111106/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Risky diving" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "174" "paginaFinal" => "176" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Cascais-Costa, G. Teixeira, L. Andrade" "autores" => array:3 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Cascais-Costa" "email" => array:1 [ 0 => "catarinacascaisc@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Teixeira" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Andrade" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Pulmonology Department, Centro Hospitalar Baixo Vouga – Hospital Infante D. Pedro, Aveiro, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 905 "Ancho" => 905 "Tamanyo" => 130200 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT scan of the patient.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The mediastinum is an anatomic compartment in the thoracic cavity located between both pleural cavities.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Pneumomediastinum is a rare clinical condition in which air leaks into the mediastinum<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> resulting from physical trauma or other situations that lead to air escaping from the lungs, airways or bowel into chest cavity.</p><p id="par0010" class="elsevierStylePara elsevierViewall">It has an incidence of 1: 44,500 patients admitted to the emergency room<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and it may also be spontaneous<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or secondary to other clinical situations (iatrogenic or non-traumatic).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> The majority of patients are males accounting for 76% of reported cases. Many authors believe that it is an underdiagnosed condition as symptoms may be easily attributed to other causes.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> One of the possible etiologies is an abnormal increase of intra-mediastinal pressures,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which forces the air into the intra-thoracic tissues to balance pressures.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Diving associated pneumomediastinum has been progressively increasing and occurs mainly during the decompression phase.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Patients may have cervical pain or swelling,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> dyspnea, cough, thoracalgia<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a> and less frequently anxiety, dysphagia, sialorrhea and fever.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the diagnosis is usually confirmed by thoracic radiography,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> this exam may be normal in about 30% of the patients<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and for these, a computed scan tomography (CT) is mandatory.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Laboratory findings are frequently inconclusive but some may reveal minor elevation of inflammatory parameters.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The authors present the case of a 21-year-old male professional fisherman, who, after 90 min of surface diving, increased dive depth to seven meters with compressed air bottle. At this point he emerged rapidly after feeling an unusual thoracic discomfort, which become worse as he ascended. Immediately after the emersion he developed complaints of cervical swelling and dysphonia, and was admitted to our hospital emergency department. Physical examination revealed a subcutaneous cervical and supraclavicular emphysema in chest radiography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which later extended to the abdominal region. The patient remained hemodynamically stable, with peripheral oximetry between 98 and 100% breathing room air.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Besides a smoking habit (seven smoking pack year) his previous medical history was unremarkable. No relevant alterations in peripheral blood analysis were observed but thoracic CT confirmed the presence of pneumomediastinum with subcutaneous emphysema (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The Hyperbaric Medicine Service decided that the patient did not need be exposed to hyperbaric treatment as there were no neurological symptoms. Nasal canula oxygen treatment was initiated to increase gas reabsorption and he was closely monitored for potential esophagic or tracheal rupture in the following 24 h.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">After that period, patient was discharged as there was total subcutaneous and mediastinal emphysema reabsorption without evident sequelae. The subsequent follow-up appointment showed no clinical or imagiological evidence of relapses. He followed a respiratory functional study as an outpatient which was normal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pneumomediastinum is usually a benign medical situation<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and although there is no consensus regarding treatment, most studies support a conservative approach with rest and analgesia.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Oxygen administration can increase gas reabsorption up to six-times and should be considered as an alternative treatment.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Relapses are rare, so a short-term medical surveillance is recommended.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This condition may be responsible for a high incidence of morbimortality such as facial or cervical lesions and esophagic or tracheal rupture,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> which justifies a complementary study carried out after the acute onset. Although spirometry is not recommended in the acute setting, however, it must be performed to exclude pulmonary fragility that may worsen the overall pneumomediastinum prognosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With this case, the authors aim to alert to a rare and otherwise underdiagnosed situation which, although benign, requires a prompt diagnosis and acknowledgement of the risks that may be associated.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no funding was received for this paper.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Author contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Catarina Cascais-Costa wrote the paper.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Gilberto Teixeira contributed to data collection.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Gilberto Teixeira and Lília Andrade contributed to the revision of the manuscript.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">All the authors read and approved the final manuscript.</p></li></ul></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Author contributions" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-01" "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 905 "Ancho" => 905 "Tamanyo" => 68539 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest radiography with evidence of pneumomediastinum.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 905 "Ancho" => 905 "Tamanyo" => 130200 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT scan of the patient.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anatomical and radiological considerations when colonic perforation leads to subcutaneous emphysema, pneumothoraces, pneumomediastinum, and mediastinal shift" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. 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| 2024 August | 87 | 42 | 129 |
| 2024 July | 84 | 31 | 115 |
| 2024 June | 89 | 31 | 120 |
| 2024 May | 71 | 40 | 111 |
| 2024 April | 63 | 34 | 97 |
| 2024 March | 61 | 27 | 88 |
| 2024 February | 45 | 29 | 74 |
| 2024 January | 57 | 20 | 77 |
| 2023 December | 73 | 39 | 112 |
| 2023 November | 58 | 44 | 102 |
| 2023 October | 63 | 39 | 102 |
| 2023 September | 43 | 27 | 70 |
| 2023 August | 42 | 26 | 68 |
| 2023 July | 75 | 35 | 110 |
| 2023 June | 40 | 19 | 59 |
| 2023 May | 66 | 25 | 91 |
| 2023 April | 41 | 23 | 64 |
| 2023 March | 65 | 26 | 91 |
| 2023 February | 45 | 21 | 66 |
| 2023 January | 55 | 24 | 79 |
| 2022 December | 86 | 24 | 110 |
| 2022 November | 83 | 36 | 119 |
| 2022 October | 94 | 50 | 144 |
| 2022 September | 69 | 52 | 121 |
| 2022 August | 48 | 31 | 79 |
| 2022 July | 64 | 52 | 116 |
| 2022 June | 34 | 39 | 73 |
| 2022 May | 49 | 36 | 85 |
| 2022 April | 60 | 42 | 102 |
| 2022 March | 59 | 48 | 107 |
| 2022 February | 56 | 60 | 116 |
| 2022 January | 69 | 55 | 124 |
| 2021 December | 38 | 48 | 86 |
| 2021 November | 38 | 37 | 75 |
| 2021 October | 54 | 67 | 121 |
| 2021 September | 53 | 43 | 96 |
| 2021 August | 80 | 50 | 130 |
| 2021 July | 43 | 35 | 78 |
| 2021 June | 59 | 48 | 107 |
| 2021 May | 45 | 51 | 96 |
| 2021 April | 88 | 88 | 176 |
| 2021 March | 45 | 53 | 98 |
| 2021 February | 28 | 23 | 51 |
| 2021 January | 26 | 28 | 54 |
| 2020 December | 38 | 36 | 74 |
| 2020 November | 50 | 20 | 70 |
| 2020 October | 54 | 25 | 79 |
| 2020 September | 53 | 45 | 98 |
| 2020 August | 86 | 38 | 124 |
| 2020 July | 106 | 62 | 168 |
| 2020 June | 98 | 42 | 140 |
| 2020 May | 156 | 68 | 224 |
| 2020 April | 39 | 13 | 52 |
| 2020 March | 30 | 20 | 50 |
| 2020 February | 29 | 23 | 52 |
| 2020 January | 43 | 24 | 67 |
| 2019 December | 38 | 20 | 58 |
| 2019 November | 25 | 17 | 42 |
Show all
