Pulmonary air leak in COVID-19: time to learn from our mistakes

Benzarti, M.; Protti, Alessandro

doi:10.1007/s00134-022-06866-z

Cited by 7 publications

(4 citation statements)

References 16 publications

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“…This could happen also due to cough efforts. This hypothesis has been supported also by other authors, as detailed in another recent editorial [ 3 ]. Furthermore, the risk of alveolar damage and rupture may be exacerbated by specific conditions, such as COVID-19 ARDS, which is characterized by microthrombi formations in the pulmonary circulation with the potential risk of superimposed ischemic damage to lung cells, and hence increased barotrauma susceptibility.…”

supporting

confidence: 83%

“…We read with great interest three recent articles published on Intensive Care Medicine [ 1 – 3 ] . In the first, Knox and colleagues present data on rate of pneumothorax/pneumomediastinum in 2211 patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) as compared with 5522 patients with non-COVID-19 ARDS [ 1 ].…”

mentioning

confidence: 99%

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Air leak, barotrauma susceptibility, and imaging in acute respiratory distress syndrome: novel application of an old tool

et al. 2022

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supporting

confidence: 83%

mentioning

confidence: 99%

Air leak, barotrauma susceptibility, and imaging in acute respiratory distress syndrome: novel application of an old tool

et al. 2022

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“…Significant hyperinflation without clear signs of overdistention (i.e., lower compliance) might reflect tissue destruction with loss of elastic recoil, as in chronic emphysema 8 . Following this hypothesis, some patients with COVID‐19 develop new emphysematous changes, 29,30 or pulmonary air leaks 31,32 . An alternative explanation for the higher compliance observed in patients with a positive response to the decrease in PEEP is a larger functional lung size (i.e., the size of the lung open to ventilation).…”

Section: Discussionmentioning

confidence: 99%

Effect of decreasing PEEP on hyperinflation and collapse in COVID‐19: A computed tomography study

Santini,

Protti,

Pennati

et al. 2024

Acta Anaesthesiol Scand

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BackgroundHigh positive end‐expiratory pressure (PEEP>10 cmH2O) is commonly used in mechanically ventilated hypoxemic patients with COVID‐19. However, some epidemiological and physiological studies indirectly suggest that using a lower PEEP may primarily and beneficially decrease lung hyperinflation in this population. Herein we directly quantified the effect of decreasing PEEP from 15 to 10 cmH2O on lung hyperinflation and collapse in mechanically ventilated patients with COVID‐19.MethodsTwenty mechanically ventilated patients with COVID‐19 underwent a lung computed tomography (CT) at PEEP of 15 and 10 cmH2O. The effect of decreasing PEEP on lung hyperinflation and collapse was directly quantified as the change in the over‐aerated (density below −900 HU) and non‐aerated (density above −100 HU) lung volumes. The net response to decreasing PEEP was computed as the sum of the change in those two compartments and expressed as the change in the “pathologic” lung volume. If the pathologic lung volume decreased (i.e., hyperinflation decreased more than collapse increased) when PEEP was decreased, the net response was considered positive; otherwise, it was considered negative.ResultsOn average, the ratio of arterial tension to inspiratory fraction of oxygen (PaO2:FiO2) in the overall study population was 137 (119–162) mmHg. In 11 (55%) patients, the net response to decreasing PEEP was positive. Their over‐aerated lung volume decreased by 159 (98–186) mL, while the non‐aerated lung volume increased by only 58 (31–91) mL. In nine (45%) patients, the net response was negative. Their over‐aerated lung volume decreased by 46 (18–72) mL, but their non‐aerated lung volume increased by 107 (44–121) mL.ConclusionIn 20 patients with COVID‐19 the net response to decreasing PEEP, as assessed with lung CT, was variable. In approximately half of them it was positive (and possibly beneficial), with a decrease in hyperinflation larger than the increase in collapse.

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“…Large hyperin ation without clear signs of overdistention (i.e., a lower compliance) might re ect tissue destruction with loss of elastic recoil, as in chronic emphysema[8]. In line with this hypothesis, new emphysema can be noted in some survivors and non-survivors of COVID-19[26,27], and pulmonary air leak is a quite common complication of this disease[28,29].…”

mentioning

confidence: 99%

Lung recruitment and hyperinflation with higher positive end-expiratory pressure in COVID-19: a computed tomography study

Protti

Santini

Pennati

et al. 2023

Preprint

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Background A higher (> 10 cmH2O) positive end-expiratory pressure (PEEP) is commonly used in patients with moderate to severe hypoxemia due to the novel coronavirus disease (COVID-19). However, compliance more commonly decreases when PEEP is increased from 10 to 15 cmH2O, as for lung hyperinflation. In this study, we directly measured lung recruitment and hyperinflation induced by increasing PEEP from 10 to 15 cmH2O in mechanically ventilated patients with COVID-19. Methods Twenty mechanically ventilated patients with COVID-19 underwent a lung computed tomography (CT) at 10 and 15 cmH2O of airway pressure. Gas exchange and compliance were then measured with 10 and 15 cmH2O of PEEP. Recruitment was computed as the decrease of the non-aerated lung volume (density above − 100 HU) and hyperinflation as the increase of the over-aerated lung volume (density below − 900 HU). If recruitment was larger than hyperinflation, the net morphological response was “recruitment”; otherwise, it was “hyperinflation”. Results With 10 cmH2O of PEEP, the median (Q1-Q3) arterial tension to the inspiratory fraction of oxygen (PaO2:FiO2) was 146 (107–197) mmHg. The net morphological response to increasing PEEP was recruitment in nine (45%) patients and hyperinflation in eleven (55%). Oxygenation improved in twelve (60%) patients, but compliance in only three (15%). Compliance with 10 cmH2O of PEEP ≤ 45 cmH2O/ml predicted net recruitment in response to increasing PEEP with a positive predictive value of 0.89 (95%-confidence intervals: 0.49-1.00) and a negative predictive value of 0.91 (0.59-1.00). Conclusions The morphological response to a higher PEEP is largely variable in patients with COVID-19, ranging from net recruitment (in half of the patients) to net hyperinflation (in the other half). Baseline compliance may help to predict the individual response to increasing PEEP.

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Pulmonary air leak in COVID-19: time to learn from our mistakes

Cited by 7 publications

References 16 publications

Air leak, barotrauma susceptibility, and imaging in acute respiratory distress syndrome: novel application of an old tool

Air leak, barotrauma susceptibility, and imaging in acute respiratory distress syndrome: novel application of an old tool

Effect of decreasing PEEP on hyperinflation and collapse in COVID‐19: A computed tomography study

Lung recruitment and hyperinflation with higher positive end-expiratory pressure in COVID-19: a computed tomography study

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