If the pneumomediastinum does not cause lung collapse there is no need to insert a drain. But you have to decrease the ventillatory pressure and check the patient xray frequently. If the lung is collapsed then you have to intevene with a chest tube. But this is important to know why  the patient had a pneumomediastinum? Did it occure any trauma of the trachea or central bronchial system or is there a centrally located tumor tissue or anything else. This is hardly able to immagine to use so high pressure on the ventillator that cause pneumomediastinum. In my cases there had been 1 patient who got pneumomediastinum after obtaining bronchoscopic sample from a centrally located malignant tissue bulk on his left main bronchi. There was no need to insert  a chest tube. 

THanks a lot DR Matesz. This patient has leukaemia and she got severe form of bleomucin toxicity with severe lung fibrosis not responding to even steroids. The ventilator settings are acceptable.

I will not in neonates unless it really compromise the ventilation.

The patient in my article - 5 y/o sp smoke inhalation, multiple intubation attempts - did not requires a chest tube.  The pneumomediastinum resolved spontaneously in 12 hours after treatment.

DEAR PROF GUSTAVSON

thanks a lot

Dear Doctor Sersar,

as mentioned no need for chest tube when there is no lung collapse. The reason of the pneumomediastinum has to be clarified. I`m working on a publication for treatment of tracheal injury after intubation. This mainly occurs during the intuition maneuver itself and can lead to tears and rupture of the floppy membrane. 

If this the case the best options are intubation, stent placement or surgery. 

If your patient is still ventilator dependent we had 2 patients similar that needed a lung transplantation. I don`t know if you have access to transplant but don`t hesitate for further questions.

Dear DR Geltner

Thanks a lot.

Our patient has severe bleomycin toxicity. She is leukaemic patient.