Pneumopericardium - Causes, Symptoms, Diagnosis, and Managment

Introduction:

Pneumopericardium is the collection of gas or air in the pericardial cavity. The pericardial cavity is the space between the two layers of the serous pericardium. The pericardium is a membrane that surrounds the heart; it has two layers called fibrous and serous. The serous layer again has two layers that enclose the fluid, the pericardial cavity. Pneumopericardium is a rare complication affecting this heart sac, which resolves on its own, but in certain cases, if the symptoms are overlooked, it can be fatal.

What Is Pneumopericardium?

The pericardium is the sac around the heart that is responsible for holding the heart in its position. It prevents the heart and chest wall from expanding when the blood volume increases, thereby ensuring smooth functioning. It lubricates the heart and protects it from infection. When air or gas enters this pericardium, it is called pneumopericardium.

Pneumopericardium can be:

• Simple: With only air in the fluid-filled cavity,

• Complicated: With air, gas, pus, or other fluids in the sac.

What Are the Causes of Pneumopericardium?

Pneumopericardium is a rare complication; in most cases, pneumopericardium occurs as a result of trauma. It can also arise due to iatrogenic causes. Spontaneous pneumopericardium is an even rarer complication that arises from HIV or tuberculosis.

• Trauma or injury is the major cause of pneumopericardium, such as stabbing, car accident, gunshot, fall from heights, severe asthma, and air pressure variations that occur due to flying or scuba diving. It can also be caused in premature infants who are kept on ventilators.

• Positive-pressure ventilation can occur in barotrauma (pressure variations) or during artificial ventilation in infants and adults. Infants who are born prematurely or adults who suffer from asthma or chronic obstructive pulmonary disease (COPD).

• Pneumopericardium can also result from interstitial gas in the pericardial sac. Gas, when under tension, can affect the pumping cycle, reduce the stroke volume and, in turn, reduce the cardiac output. In these infants, their blood pressure is reduced, and heart sounds decrease.

• Tracking of air into the pericardial space from the pneumomediastinum through the pulmonary venous system.

• Fistulization of air from:

  • Trachea or bronchus.

  • Stomach in cases of peptic ulcer, inflammatory bowel disease, or carcinoma.

  • Transverse colon due to bowel disease or carcinoma.

  • Or from the esophagus due to secondary reflux disease.

• Bacteria form gas.

• The absence of a diaphragm congenitally, too, may allow air into the pericardium.

• Lung diseases such as asthma or cystic fibrosis, or any lung disorders can cause the air in space between the lungs.

• Complications arising from lung or heart surgery.

• Infection in the pericardium.

• Abnormal openings or connections are called fistulas. Fistulas between the pericardium and windpipe can also lead to pneumopericardium.

• Pressure variations, or too much pressure on the lungs, can cause air to expel outside the lungs.

• Hemopericardium- blood inside the pericardium can occur due to blunt trauma or penetrating injury, which can quickly progress to cardiac tamponade.

What Are the Symptoms of Pneumopericardium?

Pneumopericardium has different symptoms in different individuals. It can cause pain and shortness of breath. In most cases, it resolves on its own but can be fatal if it progresses to cardiac tamponade. Extra air around the heart causes excess pressure on the heart leading to the stoppage of the heart. Symptoms of cardiac tamponade include:

• Chest pain.

• Swelling in legs and arms.

• Increase in breathing.

• Increase in pulse.

• Loss of consciousness.

• Low blood pressure.

• Cold extremities, such as fingers, toes, arms, and legs.

• Confusion.

If a patient is found to have the above symptoms, it is a medical emergency, and treatment should be given immediately to prevent loss of life.

How to Diagnose Pneumopericardium?

The first step of diagnosis is a physical examination which includes auscultation of the heart and lungs. Blood pressure is monitored, and it may be lower than normal levels.

Imaging tests may be done, such as:

• Electrocardiogram (ECG) to check heart rhythm.

• Echocardiogram to check the presence of air around the heart.

• Chest X-rays are useful, especially in premature infants. But in most cases, they exhibit a normal contour of the heart, so they may not be useful in diagnosis unless there is clinical suspicion.

• Magnetic resonance imaging (MRI).

• Computed tomography (CT).

How Is Pneumopericardium Managed?

In the majority of cases, the condition resolves on its own and does not require treatment. The doctor might need to monitor heart and lung functions. If secondary disorders are present which are responsible for pneumopericardium, such as lung disorders, they have to be treated. In rare complications such as cardiac tamponade, immediate treatment is warranted.

Pericardiocentesis is done. A long narrow tube is inserted into the pericardial sac in order to draw out the air. In extreme cases, surgery is done to remove the fluid or air from the cavity. In some cases, a chest tube may be inserted to keep the air draining. In premature infants with pneumopericardium, needle aspiration is done to give symptomatic relief; however, the recurrence rate is high in these cases and might require continuous tube drainage.

What Is the Long-Term Effect on Patients Affected With Pneumopericardium?

If patients affected with pneumopericardium have complications like cardiac tamponade, and if it is treated abruptly, then there will be no chance of complications. But if these complications are left untreated, then the patient may go into shock. This occurs when the circulatory system cannot pump sufficient amounts of blood and oxygen throughout the body. This can lead to severe complications like a multiorgan failure or even death.

What Is the Prognosis of Pneumopericardium?

Pneumopericardium usually resolves without treatment; however, the patient must be monitored for any complications. If the emergency conditions are treated immediately, the patient generally does not have any further complications. However, if these conditions are overlooked, the patient may go into shock.

Conclusion:

Pneumopericardium is the air or gas in the pericardial cavity. It mostly occurs due to trauma but can also occur spontaneously as a complication of the human immunodeficiency virus (HIV) or tuberculosis. It is a rare complication and generally resolves without treatment. ECG and Echocardiogram are useful in the diagnosis. In some cases, it can be life-threatening if cardiac tamponade occurs, and in such cases, emergency treatment is required.