COVID-19-Associated Pneumomediastinum and Pneumothorax: A Case Series

Abstract

Coronavirus disease-19 (COVID-19) causes mild to moderate illness in most patients but in some cases a severe illness may manifest. Such patients usually present with hypoxaemic respiratory failure due to acute lung injury caused by a viral infection and host-mediated cytokine storm. The characteristic radiographic findings are ground-glass opacities with consolidation in posterior basal areas of bilateral lungs and rarely pneumothorax (PTX) and pneumomediastinum (PM). The incidence of these findings was notably higher in the second wave of the pandemic in India in 2021 as compared to the first wave in 2020. The etiopathogenesis of this life-threatening condition can be due to Macklin phenomenon post-cytokinemediated diffuse alveolar injury, patient self-inflicted lung injury (P-SILI), and barotrauma in mechanically ventilated patients. The presence of pneumomediastinum is associated with higher mortality rates, prolonged intensive care unit (ICU) stays making it a poor prognostic marker. There is no consensus regarding its management in COVID-19 patients although both aggressive and conservative strategies have been tried.

Understanding Pneumomediastinum as a Complication in Patients With COVID-19: A Case Series

“…Other authors have offered a similar explanation for the development of pneumomediastinum in the nonventilated patient. 15 - 17 While the retrospective nature of our data and the wide minute-to-minute variations of minute ventilation witnessed at the bedside prohibited accurate recording of our subjects’ tidal volumes or minute ventilation, the number of subjects in our cohort, and in comparable studies, who developed pneumomediastinum while on NIV or HFNC are supportive of P-SILI playing a precipitating role. 9 …”

“…This phenomenon has also been reported in case reports and small case series. 12 - 18 Given the sample size in this case series and in comparable studies, the development of pneumomediastinum in patients not mechanically ventilated is an unignorable complication of COVID-19 worth further investigation. This includes assessing characteristics that can predispose patients to poor outcomes and exploring the pathophysiology of COVID-19 that poses an increased risk for the development of pneumomediastinum.…”

Pneumomediastinum and Pneumopericardium as Uncommon Complications of COVID-19 Infection: A Review Article

“…Surgical decompression was required for tension PM via thoracotomy [10]. Li et al [50] reported two cases where they used a pigtail catheter to decompress the mediastinum. Moreover, Wali et al [44] used subcutaneous and intrapleural chest drains.…”

Case Report: COVID-19 With Spontaneous Pneumothorax, Pneumomediastinum and Subcutaneous Emphysema

“…3 As an uncommon complication, pneumothorax, pneumomediastinum, and subcutaneous emphysema have been described; it can be spontaneous, or attributed to barotrauma and volutrauma secondary to mechanical ventilation. 4 These clinical entities are associated with rapid deterioration of clinical status or acute presentation of chest pain, tachycardia, tachypnea, subcutaneous emphysema, and hypoxemia. 4 Even if the patient does not require any invasive or non-invasive ventilator, these clinical pointers should be assessed to rule out spontaneous pulmonary air-leak syndrome.…”

“…4 These clinical entities are associated with rapid deterioration of clinical status or acute presentation of chest pain, tachycardia, tachypnea, subcutaneous emphysema, and hypoxemia. 4 Even if the patient does not require any invasive or non-invasive ventilator, these clinical pointers should be assessed to rule out spontaneous pulmonary air-leak syndrome. 5 Here we report an atypical presentation and complication case of pneumothorax, pneumomediastinum, and subcutaneous emphysema associated with COVID-19.…”