We report on a spontaneously delivered, female neonate,
born in week 35+1 of gestation, weighing 2230g. It was presented
pale, hypotonic, without respiratory movement and a heart rate
below 100 bpm. Therapeutic treatment started with bag-maskventilation,
followed by the installation of a pharyngeal tube
and CPAP-ventilation for a total of six hours applying a PEEP of
6 millibar. The X-ray displayeda pneumomediastinum, showing
elevation of both thymus lobes in the sense of an angel-wing sign
(also known as spinnaker-sail sign) [1-3] (Figure 1). Ending CPAPventilation,
treatment continued vianasal cannula without oxygen
supply for one more day, resulting in a stable respiratory status.
The radiographic follow-up presented a noticeable regression of
the pneumomediastinum (Figures 2 & 3 = 6th day of life; part C =
13th day of life), which made invasive measures redundant.
Figure 1: Part A-what goes up: Supine chest roentgenogram
of the infant on the day of birth. Angel-wing sign (white
arrows) shown as upward and lateral displacement of the
thymus (black arrows).
Figure 2: Parts B and C- must come down:Follow-up on
day six (B) and thirteen of life (C) showing a noticeable
regression of radiologic findings
Figure 3: Parts B and C - must come down: Follow-up on
day six (B) and thirteen of life (C) showing a noticeable
regression of radiologic findings
The angel-wing sign is pathognomonic for pneumomediastinum
[1]. The wedged-shaped accumulation of air in the mediastinum is
caused by applying positive pressure ventilation. Gas is displaced from interstitial emphysema of the lungs, leading to an upward
and lateral shift of thymic tissue [1,2]. Complications such as
pneumothorax, pneumo pericardium or pneumoperitoneummay
rarely occur [3]. Because of new Neonatal Resuscitation Program
guidelines recommending continuous positive airway pressure
(CPAP) for infants born with respiratory distress, a significant
increase in CPAP use and radiographs [4] may raise the incidence
of pneumomediastinum [5]. In accordance to the literature the
presented case of a pneumomediastinum resolves without specific
treatment and allows for conservative diagnostics and therapy [2].