UMEM Educational Pearls

Category: Pediatrics

Title: A young asthmatic with a bad day: Visual Diagnosis

Keywords: Macklin Phenomenon, asthma, pneumomediastinum (PubMed Search)

Posted: 9/22/2014 by Ashley Strobel, MD
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16 yo M with pleuritic right upper chest pain that started today.  He is suffering from an asthma exacerbation currently in the setting of URI with cough.  He is afebrile, tachycardic to 140-150s, respiratory rate 20, and sats 98% on room air.  ECG was performed which incidentally diagnosed this patient WPW and he went for ablation as an outpatient.  His chest x-ray showed:

Besides a bad day, what do we call this chest x-ray finding?


Macklin Phenomenon

-asthma exacerbation rupture of the alveoli causing pneumomediastinum

-typically a young man

-most common chief complaint is chest pain


Physical Exam: Hamman’s sign may be present (crackle with heartbeat) or subcutaneous emphysema


Etiology: Esophagus, lungs, or bronchial tree

Rupture of alveoli: asthma exacerbation (bronchial hyper-reactivity/constriction), barotrauma, valsalva maneuvers (lifting, childbirth), deep respiratory maneuvers/Valsalva (strenuous exercise or FVC breathing), drug use (crack cocaine causing bronchial constriction, marijuana), vomiting, blunt thoracic/abdominal trauma, scuba diving with rapid ascent


Aerodigestive tract injuries: bronchoscopy tracheobronchial injuries, laryngeal fx, bronchial fx, tracheal neoplasm, esophageal injuries (Boerhaave syndrome, paripartum, asthma exacerbation, esophageal neoplasm)


Extension from neck: head/neck sx, RPA/PTA, dental abscess/extractions


Extension from RP/chest wall: rupture RP hollow viscus



-self -limited

-treat underlying condition

-swallow study for all cases following emesis to rule out Boerhaave’s syndrome

-no repeat CXR, advance diet as tolerated, 23 hour observation

-Al-Mufarrei, et al suggest without trauma, pleural effusion, hemodynamic instability, pneumoperitoneum, or severe vomiting, the finding of spontaneous pneumomediastinum (with or without Meckler’s triad of esophageal rupture: vomiting, lower chest pain, and cervical subcutaneous emphysema after overindulgence) usually leads to unnecessary radiologic investigations, dietary restriction, and antibiotic administration

-surgery for decompression


Gray JM and Hanson GC.  Mediastinal emphysema: aetiology, diagnosis, and treatment.  Thorax.  1966; 21: 325-332.


Al-Mufarrej F, Badar J, Gharagozloo F, Tempesta B, Strother E, Margolis M.  Spontaneous pneumomediastinum: diagnostic and therapeutic intervnetions.  Journal of Cardiothoracic Surgery.  November 2008; 3: 59.


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