Subcutaneous emphysema and pneumomediastinum in patients with COVID-19 disease; case series from a tertiary care hospital in Pakistan

Abstract

Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23–75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. Eight out of ten patients had spontaneous pneumomediastinum on their initial chest x-ray in the emergency department. The median duration of assisted ventilation before the development of SE was 5.5 days (interquartile range, 5–10 days). The highest positive end-expiratory pressure (PEEP) was 10 cmH2O for patients recieving invasive mechanical ventilation, while 8 cmH2O was the average PEEP in patients who had developed subcutaneous emphysema on non-invasive ventilation. All patients received corticosteroids while six also received tocilizumab, and seven received convalescent plasma therapy, respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8−25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to COVID-19 triggered by the use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and SE whenever present, is associated with poor outcome in critically ill COVID-19 ARDS patients.

Pneumomediastinum in COVID-19: a phenotype of severe COVID-19 pneumonitis? The results of the UK POETIC survey

“…The mean age of the cohort (59.1 years) is consistent with inpatient international COVID-19 PTM cohorts from Brazil, Romania, Turkey, Pakistan and the USA [ 13 , 16 – 19 ]. It is somewhat younger than the mean age of general COVID-19 inpatients in the UK, according to the largest epidemiological study (70.4 years) [ 20 ].…”

Pneumothorax in Coronavirus Disease-19 Patients: A Retrospective Case Series

“…Contrary to our study results, Sethi et al reported that none of the 10 patients with subcutaneous emphysema and pneumomediastinum they followed up in their study had a smoking history. [32] In our literature review, we could not find any evidence that smoking facilitates the development of pneumothorax in patients with Covid-19, but the fact that 72.6% of our patients who developed pneumothorax in our study had a smoking history indicates that more studies and data are needed.…”

Complications of invasive mechanical ventilation in critically Ill Covid-19 patients - A narrative review

“…It may occur due to increased intra-alveolar pressure, high tidal volume, or high intrinsic positive end-expiratory pressure (PEEP) [ 22 ]. An alternative pathology in the development of barotrauma has also been suggested in COVID 19 patients with ARDS as most of the patients who developed barotrauma were on lung-protective ventilation, and few of the patients even developed this without any previous exposure to IMV [ 19 , 23 ]. It has been hypothesized that extensive lung damage secondary to an inflammatory response in COVID-19 patients can lead to increase respiratory drive with persistent strong spontaneous inspiratory efforts causing self-inflicted lung injury.…”