Surgical management of tension pneumomediastinum in mechanically ventilated coronavirus disease 2019 patients.

INTRODUCTION: Tension pneumomediastinum is an increasingly common condition since the COVID-19 pandemic's onset. It is a life-threatening complication with severe hemodynamic instability that is refractory to catecholamines. Surgical decompression with drainage is the key point of treatment. Various surgical procedures are reported in the literature, but no cohesive approach has yet been developed. AIM: The aim was to present the available options for surgical treatment of tension pneumomediastinum, as well as the post-interventional results. MATERIALS AND METHODS: Nine cervical mediastinotomies were performed on intensive-care unit (ICU) patients who developed a tension pneumomediastinum during mechanical ventilation. The age and sex of patients, surgical complications, pre- and post-intervention basic hemodynamic parameters, as well as oxygen saturation levels, were recorded and analyzed. RESULTS: The mean age of patients was 62±16 years (6 males and 3 females). No postoperative surgical complications were recorded. The average preoperative systolic blood pressure was 91±12 mmHg, the heart rate was 104±8 bpm, and the oxygen saturation level was 89±6%, while the short-term postoperative values changed to 105±6 mmHg, 101±4 bpm, and 94±5%, respectively. There was no long-term survival benefit, with a mortality rate of 100%. CONCLUSIONS: Cervical mediastinotomy is the operative method of choice in the presence of tension pneumomediastinum allowing an effective decompression of the mediastinal structures and improving the condition of the affected patients without improving the survival rate.

Surgical treatment of tension pneumomediastinum in patients with covid-19 at the field hospital: a case series.

BACKGROUND: Tension pneumomediastinum is one of the most serious complications in COVID-19 patients with respiratory distress requiring invasive mechanical ventilation. This complication can lead to rapid hemodynamic instability and death if it is not recognized in a timely manner and intervenes promptly. CASE PRESENTATION: We reported 7 COVID-19 patients with tension pneumomediastinum at a field hospital. All patients were critically ill with ARDS. These 7 patients, including 3 females and 4 males in this series, were aged between 39 and 70 years. Tension pneumomediastinum occurred on the first day of mechanical ventilation in 3 patients and later in the course of hospital stay, even 10 days after being intubated and ventilated. The tension pneumomediastinum caused hemodynamic instability and worsened respiratory mechanics with imminent cardiopulmonary collapse. In this series, we used two surgical techniques: (i) mediastinal decompression by suprasternal drainage with or without simultaneous pleural drainage in the first two cases and (ii) mediastinal drainage via suprasternal and subxiphoid incisions in 5 patients. The surgical procedures were feasible and reversed the pending cardiopulmonary collapse. Four patients had a favorable postprocedural period and were discharged from the intensive care center. Both patients undergoing suprasternal drainage died of failed/recurrent tension pneumomediastinum and nosocomial infection. Only one in five patients who underwent mediastinal drainage via suprasternal and subxiphoid incisions died of septic shock secondary to ventilator-associated pneumonia. CONCLUSION: Tension pneumomediastinum was a life-threatening complication in critically ill COVID-19 patients requiring mechanical ventilation. Surgical mediastinal decompression was the salvage procedure. The surgical technique of mediastinal drainage via suprasternal and subxiphoid incisions proved an advantage in tension relief, hemodynamic improvement and mortality reduction.

Tension Pneumomediastinum: A life-threatening condition in patients with COVID-19.

Tension pneumomediastinum (TPM) is a rare but potentially fatal clinical entity. TPM leads to the leakage of air into the mediastinal cavity and increased pressure in thoracic vessels, respiratory tract, and the heart. Herein, this report presents a series of five cases of coronavirus disease-2019 (COVID-19) that caused acute respiratory distress syndrome (ARDS) and TPM. All patients were male who had severe ARDS with a secondary lung infection that required invasive ventilation and had moderate positive-end expiratory pressure. All patients required vasopressors to maintain hemodynamics, and two patients needed decompression with chest drains. One patient received extracorporeal membrane oxygenation therapy. Three patients had cardiac arrest, and two patients died; thus, the mortality rate was 40%. Patients with COVID-19 pneumonia with ARDS required invasive ventilation and prone positioning. Secondary lung infection can cause TPM, and TPM may cause cardiac arrest. Management should be prompt recognition and decompression with the insertion of drains, and conservative treatment is required in stable cases. Protocols for the management of pneumomediastinum and TPM may enable early detection, earlier management, and prevention of TPM.