Ventilatory alternatives to prolong noninvasive ventilation in COVID-19 patients are attractive and poorly understood. New devices to deliver negative noninvasive ventilation as biphasic cuirass ventilation (BCV) have been introduced. BCV device assist in spontaneous breathing and support ventilation. We describe a case of the combination of BCV with high-flow nasal oxygenation (HFNO) in the treatment of a COVID-19 pneumonia patient that required prolonged NIV leading to face mask intolerance, ventilator dependency secondary to residual lung fibrosis and respiratory muscular weakness. BCV provides an efficient non-invasive approach in de-escalation of therapy and weaning of prolonged NIV.

Pneumonitis associated with fluoropolymer waterproofing agents, an entity with few reported cases, can result from occupational exposure. This condition has a rapid onset after exposure, usually resolves with supportive treatment but there could be chronic sequelae. The authors report the case of a 48-year-old male patient admitted to hospital with acute onset of dyspnea and chest pain after using an aerosolized fluoropolymer-containing waterproofing product. He presented tachypnea, leukocytosis, elevated C reactive protein, elevated serum lactate dehydrogenase and hypoxemic respiratory failure. Chest computed tomography revealed bilateral ground-glass opacities with peribronchovascular distribution. The patient was treated with oxygen and corticosteroid therapy, with clinical improvement. This chemical pneumonitis represents a diagnostic challenge since it implies a history of exposure to toxic agents and the pathophysiological mechanisms and safe exposure limits are still unknown.

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This paper consists of a clinical image of an unexpected complication of a pleural space infection that dissects through the pleura into the soft tissues of the chest in an immunocompromised patient.