Ventilator management and risk of air leak syndrome for patients with COVID-19 pneumonia

Introduction: Coronavirus disease 2019 (COVID-19) pneumonia is reportedly associated with air leak syndrome (ALS), including mediastinal emphysema and pneumothorax, and has a high mortality rate. In this study, we compared values obtained every minute from the ventilator to clarify the relationship between ventilatory management and the risk of developing ALS. Method(s): This was a single-center, retrospective, observational study for a 21-months period. Patient background, ventilator data, and outcomes were collected from adult patients with COVID-19 pneumonia on ventilator-assisted respiratory management. The primary outcome was the development of ALS within 30 days of starting ventilator management. Result(s): Of the 105 patients, 14 (13%) developed ALS. The mean positive-end expiratory pressure (PEEP) difference was 0.33 cmH2O (95% confidence interval (CI) 0.31-0.33), and it was higher in the ALS than in the non-ALS group (9.18 +/- 2.20 versus 8.85 +/- 2.63, respectively). For peak pressure, the mean difference was -0.18 cmH2O (95% CI -0.20 to -0.15), (20.70 +/- 5.30 vs. 20.87 +/- 5.65) and the mean pressure difference of -0.05 cmH2O (95% CI -0.04 to -0.07) (12.80 +/- 3.13 vs. 12.85 +/- 3.55, respectively) was also higher in the non-ALS group. The difference in the single ventilation volume per ideal body weight was 0.65 ml/kg (95% CI 0.63-0.66) (7.83 +/- 3.16 vs. 7.18 +/- 2.96, respectively), and the difference in dynamic lung compliance was 8.57 mL/cmH2O (95% CI 8.43-8.70) (50.32 +/- 31.68 vs. 49.68 +/- 15.16, respectively), and both were higher in the ALS group. The percentage of times that the ventilation volume per body weight exceeded 8 was higher in the ALS group (53.7% vs. 38.6%, p < 0.001). Conclusion(s): There was no association between higher ventilator pressures and the development of ALS. The ALS group had higher dynamic lung compliance and higher tidal volumes, which may indicate a pulmonary contribution to ALS, and ventilatory management that limits tidal volume may prevent the development of ALS.

Organizing Pneumonia and Ulcerative Colitis: A Relationship To Remember.

Ulcerative colitis (UC) is a chronic inflammatory bowel disease characterised by relapsing and remitting mucosal inflammation of the colon. Despite primarily affecting the gastrointestinal tract, UC has various extraintestinal manifestations that often affect other organs and systems. Although pulmonary involvement is uncommon, organising pneumonia (OP), which affects the lung parenchyma, is one of the potential extraintestinal manifestations of UC. We report a case of OP in a 35-year-old male with a longstanding history of UC, well-medicated with sulfasalazine (SSZ). He presented to the emergency department (ED) with complaints of fatigue, coughing, myalgia, thoracalgia and dyspnoea. A chest X-ray showed parenchymal infiltrates and computed tomography revealed bilateral consolidation. Under a preliminary diagnosis of atypical pneumonia, he was treated with an empirical broad-spectrum antimicrobial agent, which did not lead to any clinical, laboratory or imaging improvement. Furthermore, the diagnostic work-up excluded any malignancy or infectious cause. A probable diagnostic hypothesis was OP as an extraintestinal manifestation of UC or as an adverse effect of SSZ therapy. Hence, SSZ was discontinued, and he was successfully treated with corticosteroids, exhibiting significant improvements and recovering completely during the follow-up period. Despite lung involvement in UC being rare, we present this case to emphasise the importance of a thorough differential diagnosis when treating acute respiratory illness in patients with UC, including extraintestinal manifestations of UC, especially OP, even during a period of remission. We also emphasise the importance of early initiation of corticosteroid therapy to prevent major complications and promote recovery.

Air Leak Syndrome In Patients With Severe Covid Pneumonia.

Abstract: There are number of emerging studies that link the air leak syndrome (ALS) with COVID 19 disease but still data to explain the association, incidence and outcome in these patients is lacking. We aim to understand the risk factors and clinical outcome of these air leakage events in COVID 19 patients admitted to our institution. Methods: This is a single-centered case series conducted at the COVID unit of the SMBBIT in Karachi, Pakistan. Data collection was done from April 24, 2020 to June 10, 2021. Results: There were 19 patients with severe COVID pneumonia who developed air leaks. Most common finding was subcutaneous emphysema 94%. Four patients (21%) didn't receive positive pressure ventilation in any form. Median time of developing air leak from admission is 5 [2-9] and from PPV is 2 [1-3] days. There was high percentage of mortality 84.5 % in these patients.

Severe Air Leak Syndrome Associated with Sars-Cov-2 and Corona-Oc43 Infections

BACKGROUND AND AIM: Air leak syndrome is an uncommon complication for viral infections in pediatric patients and has been associated with pneumothoraces, empyemas, necrotizing pneumonias, barotrauma, and other underlying lung diseases. We present a case series of three patients with Coronavirus infections that developed severe air leak syndrome, two of which were placed on venovenous-extracorporeal membrane oxygenation (VV-ECMO). METHOD(S): Patient 1 (Pt1) is a 6-month-old male with a history of prematurity presenting with fever, cough, and respiratory failure with severe air leak syndrome requiring VV-ECMO support with SARS-CoV2. Patient 2 (Pt2) is a previously healthy 19-month-old female presenting with fever, cough, and respiratory failure with multiple pneumatoceles and pneumothoraces in the setting of coronavirus-OC43 requiring VV-ECMO support. Patient 3 (Pt3) is a previously healthy 25-day-old infant presenting with shock, cyanosis, apnea, multiple pneumothoraces and pneumatoceles, and subsequent respiratory failure with SARS-CoV2. RESULT(S): Pt1 and Pt2 developed multiple pneumothoraces with tension physiology and severe hypoxemia from necrotizing pneumonia with severe air leak, requiring multiple chest tubes, JET ventilation, and ultimately VV-ECMO support (see Figure 1). Pt3 developed multiple loculated pneumothoraces that necessitated surgically-placed chest tubes for decompression and JET ventilation for a 3+ week course. CONCLUSION(S): These cases highlight severe air leak syndromes as an infrequent and life-threatening complication correlated with Coronavirus infections. Viral illnesses such as SARS-CoV2 and Corona-OC43 and their associated multiorgan system disease have more recently impacted a larger number of pediatric patients and must be further evaluated to better understand underlying etiologies and compare management strategies. (Figure Presented).

11th World Congress of the World Federation of Pediatric Intensive and Critical Care Societies

The proceedings contain 536 papers. The topics discussed include: burden and predictors of mortality of acute tropical infections in pediatric intensive care unit in a tertiary care teaching hospital in northern India;application of metagenomic next-generation sequencing (MNGS) in diagnosing pneumonia of children;serum vimentin predicts mortality in pediatric severe sepsis: a prospective observational study;impact of age and airway resistance on the reliability of peak inspiratory pressure to estimate plateau pressure in children;incidence of air leak syndrome in pediatric patients with SARS-CoV-2 pneumonia and respiratory failure;regional compliance guidance positive end-expiratory pressure render Pendelluft in pediatric acute respiratory syndrome;implementation of guidelines reduces non-invasive ventilation days for patients managed on high dependency unit;adequacy of energy and protein administration during nutritional support in Latin American critically ill children: a preliminary report of the NUTRIPIC study;and relationship between early enteral nutrition and clinical outcomes in critically ill pediatric populations: a systematic review.

Pneumomediastinum and Pneumopericardium as Uncommon Complications of COVID-19 Infection: A Review Article.

There is an emerging body of literature describing an increasing incidence of pneumomediastinum and, to a lesser extent, pneumopericardium as a complication of COVID-19. However, the literature lacks information regarding patients' characteristics and a general view of this unusual condition. The purpose of this paper is to summarize the current literature on this phenomenon. In this study, we summarize the risk factors/etiology, imaging modalities, management, and prognosis of known cases in the literature. In total, 48 articles were included in the study, ranging from case reports to case series. Most patients were male (83.3%). The overall mortality rate was 27.1% and the recovery rate was 62.5%.

COVID-19 Pneumomediastinum: Possible Role of Transesophageal Echo in Bedside Percutaneous Bicaval Double-Lumen ECMO Cannulation in Children. A Case Report.

COVID-19 is generally uneventful in children. Only 8% of severe acute respiratory distress syndrome corona virus 2 pediatric patients require intensive care; of these, 1% may need extracorporeal membrane oxygenation. Preexisting medical conditions are an independent risk factor for pediatric intensive care unit admission. We describe the case of an 11-year-old girl with adenosine deaminase 2 deficiency who presented severe COVID-19 acute respiratory distress syndrome, complicated by a massive air leak syndrome. The respiratory failure, refractory to conventional support, required veno-venous extracorporeal membrane oxygenation. To prevent viral diffusion, bicaval double-lumen cannulation was performed percutaneously at the bedside under exclusive echo guidance. Because of pneumomediastinum, pneumothorax, and subcutaneous emphysema, ultrasound visualization of the heart was possible only with transesophageal echo. To our knowledge, this is the first description of a transesophageal echo guided bedside percutaneous bicaval double-lumen extracorporeal membrane oxygenation cannulation in a pediatric patient. Pitfalls of the technique are highlighted.

Spontaneous Air-leak Syndrome and COVID-19: A Multifaceted Challenge.

Spontaneous air-leak syndromes have emerged as rare but significant complication of Coronavirus disease-2019 (COVID-19) pneumonia in the last few months. This complication has been documented in both spontaneous and mechanically ventilated patients. Although few studies have used computed tomographic scans to confirm the diagnosis, this could be challenging in resource-limited setup. We present a series of 15 cases that highlight the clinical heterogeneity with respect to stage of illness, ventilatory status, and varied clinical scenarios at the time of development of these syndromes. All cases in our series were diagnosed clinically and confirmed by bedside chest X-ray and were managed promptly. Though mortality was not so infrequent in our experience, these air-leak syndromes were not directly attributed as cause of death in these patients. Therefore, high level of clinical suspicion and vigilance is necessary to identify and manage cases of air-leak syndrome. How to cite this article: Sabharwal P, Chakraborty S, Tyagi N, Kumar R, Taneja A. Spontaneous Air-leak Syndrome and COVID-19: A Multifaceted Challenge. Indian J Crit Care Med 2021;25(5):584-587.