Predictors of Pneumothorax/Pneumomediastinum in Mechanically Ventilated COVID-19 Patients

Abstract

Objective To determine the incidence, predictors, and outcome of pneumothorax (PNX)/pneumomediastinum (PMD) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS). Design Observational study. Setting Tertiary-care university hospital. Participants One hundred sixteen consecutive critically ill, invasively ventilated patients with COVID-19 ARDS. Interventions The authors collected demographic, mechanical ventilation, imaging, laboratory, and outcome data. Primary outcome was the incidence of PNX/PMD. Multiple logistic regression analyses were performed to identify predictors of PNX/PMD. Measurements and Main Results PNX/PMD occurred in a total of 28 patients (24.1%), with 22 patients developing PNX (19.0%) and 13 developing PMD (11.2%). Mean time to development of PNX/PMD was 14 ± 11 days from intubation. The authors found no significant difference in mechanical ventilation parameters between patients who developed PNX/PMD and those who did not. Mechanical ventilation parameters were within recommended limits for protective ventilation in both groups. Ninety-five percent of patients with PNX/PMD had the Macklin effect (linear collections of air contiguous to the bronchovascular sheaths) on a baseline computed tomography scan, and tended to have a higher lung involvement at intensive care unit (ICU) admission (Radiographic Assessment of Lung Edema score 32.2 ± 13.4 v 18.7 ± 9.8 in patients without PNX/PMD, p = 0.08). Time from symptom onset to intubation and time from total bilirubin on day two after ICU admission were the only independent predictors of PNX/PMD. Mortality was 60.7% in patients who developed PNX/PMD versus 38.6% in those who did not (p = 0.04). Conclusion PNX/PMD occurs frequently in COVID-19 patients with ARDS requiring mechanical ventilation, and is associated with increased mortality. Development of PNX/PMD seems to occur despite use of protective mechanical ventilation and has a radiologic predictor sign.

Pulmonary Barotrauma in COVID-19 Patients: Invasive versus Noninvasive Positive Pressure Ventilation

“…26,27 Belletti et al evaluated predictors of PNX/PMD in mechanically ventilated COVID-19 patients and concluded that delayed intubation was an independent predictor of PNX/PMD development. 28 In that study, the group who developed PBT had a longer time from symptoms onset to intubation than the group who did not develop PBT (13 vs 10 days, p=0.004). This higher incidence of PBT in NIPPV, as well as the reported cases of spontaneous PNX, may support that the underlying cause of PNX/PMD is due to an underlying virus-induced mechanism as part of the natural course/sequela of the SARS-CoV -2 disease rather than a mechanical PPV-induced complication caused by high transpulmonary pressure.…”

“…45,46 In a study by Capaccione et al, the time from intubation to PNX event was 14.9 days which is similar to that described by Belletti et al, in which the time from intubation to PNX was 14 days. 15,28 Most patients who developed PBT in our study died (88%). The occurrence of PBT did not change the overall outcome of our study population.…”

“…47,48 The mortality rate reported by Belletti et al was 61% in patients who developed PNX/PMD, higher than those who did not have PNX/PMD (39%, p=0.04). 28 Abdallat et al described a case series of 25 patients with COVID-19 infection who developed PBT with a mortality rate of 64%. 49 Martinelli et al indicated that although post-PNX survival was lower in patients receiving IPPV than patients who were not intubated, no significant difference was found between patients receiving IPPV or those not receiving IPPV ventilation.…”

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

“…Pneumomediastinum (PMD) and pneumothorax (PNX) occur frequently in mechanically ventilated patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) [ 1 ], with a reported incidence up to 24% in the first Italian pandemic wave [ 2 ].…”

Pneumothorax in a COVID-19 Patient Receiving Long-Term Mechanical Ventilation

“…Pneumothorax and pneumomediastinum are relatively common complications in patients with extensive alveolar damage requiring mechanical ventilation 1 . In lung areas exposed to high pressure during mechanical ventilation, alveolar rupture may develop and cause pneumothorax 2 .…”