Pneumothorax and pneumomediastinum in COVID-19 acute respiratory distress syndrome

Abstract

COVID-19 has involved numerous countries across the globe and the disease burden, susceptible age group; mortality rate has been variable depending on the demographical profile, economic status, and health care infrastructure. In the current clinical environment, COVID-19 is one of the most important clinical differential diagnoses in patients presenting with respiratory symptoms. The optimal mechanical ventilation strategy for these patients has been a constant topic of discussion and very importantly so, since a great majority of these patients require invasive mechanical ventilation and often for an extended period of time. In this report we highlight our experience with a COVID-19 patient who most likely suffered barotrauma either as a result of traumatic endotracheal intubation or primarily due to COVID-19 itself. We also aim to highlight the current literature available to suggest the management strategy for these patients for a favorable outcome. The cases described are diverse in terms of age variance and other comorbidities. According to the literature, certain patients, with COVID-19 disease and spontaneous pneumothorax were noted to be managed conservatively and oxygen supplementation with nasal cannula sufficed. Decision regarding need and escalation to invasive mechanical ventilation should be taken early in the disease to avoid complications such as patient self-inflicted lung injury (P-SILI) and barotrauma sequelae such as pneumothorax and pneumomediastinum Recent systematic review further supports the fact that the use of non-invasive ventilation (NIV) in certain patients with COVID-19 pneumonia may give a false sense of security and clinical stabilization but has no overall benefit to avoid intubation. While invasive mechanical ventilation may be associated with higher rates of barotrauma, this should not mean that intubation and invasive mechanical ventilation should be delayed. This becomes an important consideration when non-intensivists or personnel with less experience provide care for this vulnerable patient population who may rely too heavily on NIV to avoid intubation and mechanical ventilation.

Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate–Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital

“…This radiologic appearance could be identified on the chest CT, representing macroscopic evidence of the proposed virus-induced frailty of airways tissue ( Figure 5 a). It is possible that the coexistence of all these factors can lead to the increased risk of developing PNX/PNM, especially in patients treated with prolonged positive-pressure ventilation [ 23 , 24 ].…”

Predictors of Mortality and Orotracheal Intubation in Patients with Pulmonary Barotrauma Due to COVID-19: An Italian Multicenter Observational Study during Two Years of the Pandemic

“…The mechanism of P-SILI is related to a deep inspiratory swing of the patients with increased negative pleural pressure and increased transpulmonary pressure, which can predispose the patient to pulmonary barotrauma. While we were unable to prove this in our study due to a lack of data on tidal volume and pressure support, it remains an area of potential investigation for future research [ 51 ].…”

Bronchopulmonary Fistula Development in an Elderly Male With COVID-19 Infection

“…Reports suggest the incidence of barotrauma to be up to 40% in patients requiring invasive ventilation, and up to 8.1% in patients requiring non-invasive ventilation. Furthermore, barotrauma has been associated with up to 60% increased mortality in this patient population [ 3 ].…”