Pneumothorax/pneumomediastinum in non-intubated COVID-19 patients: Differences between first and second Italian pandemic wave

Palumbo, Diego; Campochiaro, Corrado; Belletti, Alessandro; Marinosci, A; Dagna, Lorenzo; Zangrillo, Alberto; Cobelli, Francesco De

doi:10.1016/j.ejim.2021.03.018

Cited by 33 publications

(38 citation statements)

References 5 publications

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“…Most of previously published studies reported no significant differences among mechanical ventilation settings/parameters between patients who developed barotrauma and those who did not. They also found a trend towards lower age and higher use of steroids in pneumothorax patients, which were also suggested by other Authors [2,16].…”

supporting

confidence: 82%

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

Belletti

Landoni

Zangrillo

2021

Respiratory Medicine

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We read with great interest the article by Chopra et al. recently published on Respiratory Medicine [1].In their multicenter study, the Authors present incidence, clinical characteristics and outcome of pneumothorax in critically ill patients with coronavirus disease 2019 . They found that pneumothorax rate among invasively ventilated COVID-19 patients is 80/594 (13 %), and mortality rate for patients who developed pneumothorax is 50/80 (62 %). On the contrary, among 160 randomly selected invasively ventilated COVID-19 patients without pneumothorax, mortality was 78/ 160 (49 %).We recently published a systematic review on rate of barotrauma among invasively ventilated COVID-19 patients [2]. Our pooled analysis included data from 13 studies and 1814 patients [3][4][5][6][7][8][9][10][11][12][13][14][15] and we found that pooled estimate of pneumothorax rate was 10.7 % (95 % confidence interval [CI] = 6.7 %-14.7 %), while overall rate of barotrauma event was 16.1 % (95 % CI = 11.8 %-20.4 %). In addition, we found an overall mortality rate for COVID-19 patients who developed barotrauma of 61.6 % (95 % CI = 50.2 %-73.0 %), as compared with a mortality of 49.5 % (95 % CI = 41.1 %-58.0 %) for COVID-19 patients who did not develop barotrauma.We are pleased to read that our findings are further reinforced by another study, that confirms that pneumothorax rate among mechanically ventilated COVID-19 patients is between 10 and 15 %. Indeed, after including the study by Chopra et al. in an updated meta-analysis, the pooled pneumothorax rate is 11.1 % (95 % CI = 7.4 %-14.8 %) (Fig. 1), while the overall barotrauma rate is 15.4 % (95 % CI = 11.7 %-19 %) (Fig. 2). Furthermore, the study by Chopra et al. also confirms a mortality rate above 60 % for COVID-19 patients with barotrauma

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supporting

confidence: 82%

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

Belletti

Landoni

Zangrillo

2021

Respiratory Medicine

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“…3 cases of SPM out of 720 patients (frequency 0.42%) have been identified in our radiological department since November 2020, but no cases were noted earlier, during the first wave of the pandemic. These observations are in accordance with the results of larger studies [ 13 , 14 , 15 ]. In fact, in their study of 4081 hospitalized COVID-19 patients Brito et al [13] report a frequency of 0.5 % and in their study of 1648 patients Cut et al [14] report a frequency of 0.66%.…”

Section: Discussionsupporting

confidence: 93%

“…In fact, in their study of 4081 hospitalized COVID-19 patients Brito et al [13] report a frequency of 0.5 % and in their study of 1648 patients Cut et al [14] report a frequency of 0.66%. Moreover, Palumbo et al [15] point out the significantly higher rate of the complication during the second wave of the pandemic.…”

Section: Discussionmentioning

confidence: 99%

Spontaneous pneumomediastinum and COVID-19 pneumonia: Report of three cases with emphasis on CT imaging

Kalpaxi

Kalokairinou

Katseli

et al. 2021

Radiology Case Reports

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Spontaneous pneumomediastinum (SPM) is a rare complication of coronavirus disease 2019 (COVID-19). The published literature consists mainly of case reports and small case series. There are still many questions regarding the pathogenesis, the prognostic significance and the implications on patient management. In our hospital three COVID-19 patients developed SPM: one on admission at the emergency department and the other two during hospitalization. In this study we describe their clinical course and computed tomography (CT) findings. All of them had severe disease according to the total severity score on admission CT. The management of pneumomediastinum was conservative and follow-up CT showed resolution in all patients. As the correlation between extension of parenchymal lung lesions and development of pneumomediastinum is still under investigation, we highlight the importance of reporting the severity score on chest CT in order to obtain more comparable results between different studies. Furthermore, in this tragic circumstance we also had the opportunity to familiarize ourselves with the otherwise uncommon occurrence of air along the bronchovascular sheaths (Macklin effect) and evaluate the ability of CT to detect it.

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“…COVID-19 ARDS patients are thought to be indeed more vulnerable to PMD/PNX occurrence as compared with patients with ARDS due to other than COVID-19 causes [ 1 , 3 ]; a higher than expected incidence of PMD/PNX was also observed in COVID-19 patients not requiring invasive mechanical ventilation [ [3] , [4] , [5] , [6] ]. Furthermore, despite employment of lung protective ventilation strategies, these complications have difficult, non-standardized management, and are associated with increased risk of mortality [ 2 , 7 , 8 ].…”

Section: Introductionmentioning

confidence: 99%

A radiological predictor for pneumomediastinum/pneumothorax in COVID-19 ARDS patients

Palumbo

Zangrillo

Belletti

et al. 2021

Journal of Critical Care

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Purpose To determine whether Macklin effect (a linear collection of air contiguous to the bronchovascular sheath) on baseline CT imaging is an accurate predictor for subsequent pneumomediastinum (PMD)/pneumothorax (PNX) development in invasively ventilated patients with COVID-19-related acute respiratory distress syndrome (ARDS). Materials and methods This is an observational, case-control study. From a prospectively acquired database, all consecutive invasively ventilated COVID-19 ARDS patients who underwent at least one baseline chest CT scan during the study time period (February 25th, 2020–December 31st, 2020) were identified; those who had tracheal lesion or already had PMD/PNX at the time of the first available chest imaging were excluded. Results 37/173 (21.4%) patients enrolled had PMD/PNX; specifically, 20 (11.5%) had PMD, 10 (5.8%) PNX, 7 (4%) both. 33/37 patients with subsequent PMD/PNX had Macklin effect on baseline CT (89.2%, true positive s) 8.5 days [range, 1–18] before the first actual radiological evidence of PMD/PNX. Conversely, 6/136 patients without PMD/PNX (4.4%, false positive s) demonstrated Macklin effect ( p < 0.001). Macklin effect yielded a sensitivity of 89.2% (95% confidence interval [CI]: 74.6–96.9), a specificity of 95.6% (95% CI: 90.6–98.4), a positive predictive value (PV) of 84.5% (95% CI: 71.3–92.3), a negative PV of 97.1% (95% CI: 74.6–96.9) and an accuracy of 94.2% (95% CI: 89.6–97.2) in predicting PMD/PNX (AUC:0.924). Conclusions Macklin effect accurately predicts, 8.5 days in advance, PMD/PNX development in COVID-19 ARDS patients.

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Pneumothorax/pneumomediastinum in non-intubated COVID-19 patients: Differences between first and second Italian pandemic wave

Cited by 33 publications

References 5 publications

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

Spontaneous pneumomediastinum and COVID-19 pneumonia: Report of three cases with emphasis on CT imaging

A radiological predictor for pneumomediastinum/pneumothorax in COVID-19 ARDS patients

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