Incidence of Barotrauma in Patients With COVID-19 Pneumonia During Prolonged Invasive Mechanical Ventilation – A Case-Control Study

Abstract

Background: SARS-CoV2 can cause pulmonary failure requiring prolonged invasive mechanical ventilation (MV). Lung protective ventilation strategies are recommended in order to minimize ventilator induced lung injury. Whether patients with COVID-19 have the same risk for complications including barotrauma is still unknown. Therefore, we investigated barotrauma in patients with COVID-19 pneumonia requiring prolonged MV. Methods: All patients meeting diagnosis criteria for ARDS according to the Berlin Definition, with PCR positive SARS-CoV2 infection and prolonged mechanical ventilation, defined as ≥2 days, treated at our ARDS referral center between March and April 2020 were included in a retrospective registry analysis. Complications were detected by manual review of all patient data including respiratory data, imaging studies, and patient files. Results: A total of 20 patients with severe COVID-19 pulmonary failure (Overall characteristics: median age: 61 years, female gender 6, median duration of MV 22 days) were analyzed. Eight patients (40%) developed severe barotrauma during MV (after median 18 days, range: 1-32) including pneumothorax (5/20), pneumomediastinum (5/20), pneumopericard (1/20), and extended subcutaneous emphysema (5/20). Median respirator settings 24 hours before barotrauma were: Peak inspiratory pressure (Ppeak) 29 cm H2O (range: 27-35), positive end-expiratory pressure (PEEP) 14 cm H2O (range: 5-24), tidal volume (VT) 5.4ml/kg predicted body weight (range 0.4-8.6), plateau pressure (Pplateau) 27 cm H2O (range: 19-30). Mechanical ventilation was significantly more invasive on several occasions in patients without barotrauma. Conclusion: Barotrauma in COVID-19 induced respiratory failure requiring mechanical ventilation was found in 40% of patients included in this registry. Our data suggest that barotrauma in COVID-19 may occur even when following recommendations for lung protective MV.

Pneumomediastinum in Acute Respiratory Distress Syndrome from COVID-19

“…We report five patients with pneumomediastinum of 92 critically ill, mechanically ventilated adults with ARDS from COVID-19 at our institution from March 1, 2020, through August 31, 2020 ( Figure 1 ). Unlike other reports ( 4 , 5 ), no patient had pneumothorax or required tube thoracostomy at diagnosis, suggesting alveolar rupture occurred without disruption of visceral pleura. Pneumomediastinum developed between 24 hours before and 9 days after initiation of mechanical ventilation without evidence of tracheal injury or the use of recruitment maneuvers.…”

Pulmonary barotrauma in mechanically ventilated coronavirus disease 2019 patients: A case series

“…Additionally, a case-report by Udi et al reported 8 patients (40%) developed severe barotrauma during mechanical ventilation. Of the 8 patients, one had tension pneumothorax and four had pneumothorax not causing hemodynamic compromise [ 19 ]. All patients received chest tubes.…”

A Pictorial Review of the Role of Imaging in the Detection, Management, Histopathological Correlations, and Complications of COVID-19 Pneumonia

“…Other common chest complications of COVID-19 pneumonia include PNX, PM, pneumopericardium, and subcutaneous emphysema, which are usually secondary to pulmonary barotrauma from mechanical ventilation in the ICU ( Figure 13 ) [ 184 ]. They are usually associated with a long hospital stay and higher mortality and occurred in 15 to 40% of COVID-19 patients who underwent mechanical ventilation [ 185 , 186 ]. Mechanical ventilation with high positive end-expiratory pressure (PEEP) can increase high intra-alveolar pressure, causing alveolar rupture through the disproportionate distribution of volume and pressure from the ventilator with air dissection along the bronchovascular sheets toward the mediastinum, leading to PM.…”

“…Occasionally, air in the mediastinum can escape into the pleural space and cause pneumothorax (PNX), or through the parietal pericardium and cause pneumopericardium. Air can also travel toward the thoracic inlet and into neck soft tissue, causing subcutaneous cervical-facial emphysema, and into the peritoneal spaces of the abdomen, causing pneumo-retroperitoneum [ 185 , 186 , 187 ]. Gattinoni et al [ 178 ] found that in critically ill COVID-19 patients, the incidence of PNX increased in those who were mechanically ventilated for a long period of time.…”

“…It has also been reported that corticosteroid use may contribute to the development of SMP by weakening the pulmonary interstitial tissue [ 184 , 186 ]. SPX without SPM can be due to structural modification, such as cystic and fibrotic changes, that can occur in COVID-19 pneumonia [ 185 , 186 , 187 ]. Zantah et al [ 186 ] reported six cases of SPX in 902 patients with COVID-19 pneumonia with an incidence of 0.66%.…”