Q: 28 year old male presented to ED with chest pain after inhalation of crack cocaine. CXR showed pneumomediastinum which was confirmed by CT scan. What is the modus operandi of pneumomediastinum associated with inhalation of crack cocaine?


Answer: There is a general misconception that pneumomediastinum (and/or pneumothorax) associated with crack cocaine is due to drug itself. Actually, it is  likely due to valsalva maneuver usually performed after inhalation. This is the reason that pneumomediastinum (and/or pneumothorax) is a rare occurrence after intranasal cocaine. It may be interesting to know that it is a common practice among crack cocaine smokers not only to perform a valsalva maneuver after inhalation but partners also exhale forcefully into each other's mouths (to increase uptake of the drug), causing  pneumothorax, pneumomediastinum, or even pneumopericardium due to barotrauma.


References:

1. Maeder M, Ullmer E. Pneumomediastinum and bilateral pneumothorax as a complication of cocaine smoking. Respiration 2003; 70:407. 

2. Alnas M, Altayeh A, Zaman M. Clinical course and outcome of cocaine-induced pneumomediastinum. Am J Med Sci 2010; 339:65.