Spontaneous pneumomediastinum, subcutaneous emphysema and pneumothorax in non-intubated patients with COVID-19 pneumonitis: a retrospective case note review of a single centre experience

Introduction: Emerging evidence suggests COVID-19 is associated with a higher incidence of pneumomediastinum (PM), subcutaneous emphysema (SCE) and pneumothorax (PTX). Aims and objectives: To determine whether the presence of concurrent SCE and PTX in addition to PM were associated with a higher risk of admission to ITU or death compared to PM alone. Method(s): Study period: September 2020 to June 2021. Patients identified through the Trust Operations Centre prospective records of all COVID-19 admissions. PACS radiology system used to further identify patients who had CT scans. Every CT scan reviewed for presence of PM, SCE and PTX. Case notes reviewed retrospectively. Statistical analyses: GraphPad Prism;group difference assessments: Kruskal-Wallis tests. Result(s): PM was confirmed on CT scans in 24 patients. Mean age was 63.29 years (SD+/-10.05). 66.7% were male. 83.3% required CPAP;12.5% venturi masks and 4.2% optiflow. In addition to PM, 11 patients had SCE, 8 had PTX and 4 pneumopericardium. There was no significant difference in admission SpO2, maximum FiO2 and maximum PEEP in PM patients who developed SCE or PTX (p=0.94 and 0.91) versus PM alone. ~40% of patients in each group developed pneumonia or sepsis. Higher percentages of SCE or PTX patients were admitted to ITU (81.7% and 87.5%) compared to PM alone (62.5%), however this was not statistically significant, nor associated with higher risk of death (p=0.10;p=0.89 respectively). Conclusion(s): PM patients with and without SCE and PTX had no significant differences in respiratory support mechanisms, PEEP, FiO2, ITU admission or risk of death.

A rare complication of pericardiocentesis: Pneumopericardium.

Pneumopericardium is the presence of air in the pericardial sac. Pneumopericardium after pericardiocentesis has been rarely reported in the literature. In the present case, we report a patient who presented with tamponade physiology during COVID-19 and developed pneumopericardium after emergency pericardiocentesis. Immediate recognition and treatment are crucial and chest x-ray, thorax computerized tomography, and transthoracic echocardiography (TTE) are used for diagnosis.

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.

Incidence of Air Leak Syndrome in Pediatric Patients with Sars-Cov-2 Pneumonia and Respiratory Failure

BACKGROUND AND AIM: Air Leak syndromes (ALS), such as pneumothorax, pneumomediastinum, pneumopericardium, subcutaneous emphysema, and pneumoperitoneum, have been observed in adult patients with respiratory failure secondary to severe acute respiratory syndrome coronavirus-2 SARS-CoV-2 pneumonia with an incidence of approximately ~ 1%. Our aim is to describe the incidence of ALS in children with SARS-CoV-2 pneumonia admitted with respiratory failure to the pediatric intensive care unit (PICU) at 2 large Pediatric Children's Hospitals. METHOD(S): IRB exempted retrospective search of electronic medical record data from patients admitted to the PICUs (Wolfson Children's Hospital and UF Health Shands Children's Hospital) with a diagnosis of SARS-CoV-2 pneumonia with respiratory failure from March 1st, 2020, to December 31, 2021. Diagnosis of SARS-CoV-2 was done with real-time reverse transcriptase PCR performed on nasopharyngeal swab. RESULT(S): 104 patients met criteria for inclusion. The age of the patients ranged from 1 month to 18 years old. Twelve patients (11.5%) presented with or developed ALS including pneumothorax, pneumomediastinum, pneumopericardium, subcutaneous emphysema, and pneumoperitoneum. Of the twelve patients with ALS, three required a chest tube, two were placed on extracorporeal membrane oxygenation (ECMO) and three died. CONCLUSION(S): ALS, with an incidence of 11.5%, are not uncommon in patients with SARS-CoV-2 pneumonia and respiratory failure. ALS contribute to morbidity and was associated with a mortality rate of 25%. To understand if SARS-CoV-2 pneumonia has an intrinsic pathobiology that predispose to ALS, we will perform a propensity score matching with a cohort group considering age-severity of illness and intensity of interventions.

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. Copyright © 2023, Iranian Heart Association. All rights reserved.

Spontaneous pneumopericardium and pneumomediastinum as atypical complication for SARS-CoV-2.

SARS-CoV-2 (COVID-19) disease is an infection caused by a new emerging coronavirus, the most common clinical manifestations include fever, dry cough, dyspnea, chest pain, fatigue, and myalgia, sometimes it may present with atypical manifestations such as spontaneous pneumothorax and pneumomediastinum that occur in a minority of patients. We report a case of spontaneous pneumopericardium in a 60-year-old male, without comorbidities or a history of trauma, with pneumonia due to SARS-CoV-2.

La enfermedad por SARS-CoV-2 (COVID-19) es una infección causada por un nuevo coronavirus emergente. Las manifestaciones clínicas más comunes incluyen fiebre, tos seca, disnea, dolor de pecho, fatiga y mialgias. En ocasiones puede presentarse con manifestaciones atípicas, como neumotórax espontáneo y neumomediastino, que ocurren en una minoría de pacientes. Reportamos un caso de neumopericardio espontáneo en un varón de 60 años, sin comorbilidad ni antecedente de traumatismo, con neumonía por SARS-CoV-2.

TENSION PNEUMOMEDIASTINUM RESULTING IN OBSTRUCTIVE SHOCK IN COVID-19

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Pneumomediastinum is often witnessed in intensive care units secondary to mechanical ventilation, or blunt and penetrating trauma. However, it is rare for patients to develop tension pneumomediastinum. Tension pneumomediastinum within the context of Covid-19 pneumonia is even more rarely discussed. Here we discuss a patient with Covid-19 pneumonia who developed rapidly progressive tension pneumomediastinum. CASE PRESENTATION: 72-year-old male was admitted to the ICU for Covid-19 infection causing hypoxemic respiratory failure requiring mechanical ventilation. On ICU day 2 the patient developed sudden worsening of shock requiring multiple pressors. Clinical exam revealed extensive subcutaneous crepitus in the supraclavicular region extending to the neck. Chest XR showed extensive pneumomediastinum and pneumopericardium and no pneumothorax. There was concern for ongoing obstructive shock due to cardiac tamponade, cardiology was called to bedside to perform POC ultrasound. The heart could not be visualized due to subcutaneous air. CT scan showed extensive mediastinal air and subcutaneous emphysema. The significantly increasing air in the retrocardiac space and concavity of the atria were concerning for worsening tension physiology. Cardiothoracic surgery decided to place a mediastinal drain and create a pericardial window. In the hours that followed, the patient's hemodynamics improved, and his pressor requirement decreased to only low dose norepinephrine. On ICU day 3 he developed worsening severe mixed acidosis. On day 4, the patient was requiring over 100mcg per hour of norepinephrine and labs showed worsening renal and liver failure. In the afternoon of day 4, the patient experienced a cardiac arrest and expired. DISCUSSION: Most reported cases of pneumomediastinum with associated pneumopericardium are self-limited, however 38% of cases progress to create tension pneumomediastinum and life-threatening cardiac tamponade.1 There are few reports of tension pneumomediastinum complicated by pneumopericardium in patients with Covid-19,2 but there is concern that this condition occurs more frequently in critically ill patients with Covid-19.3 The management of cardiac tamponade as a result of tension pneumopericardium may include pericardiocentesis,2 placement of a pericardial window, or insertion of a mediastinal drain.3 While several reported patients who underwent these procedures survived to discharge successfully,1,3 there are also reports that suggest that the development of subcutaneous emphysema and pneumomediastinum may be indicative of worsening prognosis.3 CONCLUSIONS: The ideal management of tension pneumomediastinum in Covid-19 is not clear and prognosis of patients who develop tension pneumomediastinum is highly varied. Further study is needed to develop tools to identify pneumomediastinum with the potential to develop tension physiology and progress to obstructive shock. Reference #1: Hazariwala, V., Hadid, H., Kirsch, D. et al. Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report. J Cardiothorac Surg 15, 301 (2020). https://doi.org/10.1186/s13019-020-01308-7 Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984;37(6):511-518. doi:10.1016/s0003-4975(10)61146-0 Reference #3: Al-Azzawi M, Douedi S, Alshami A, Al-Saoudi G, Mikhail J. Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis? Am J Case Rep. 2020;21:e925557-1-e925557-6. doi:10.12659/AJCR.925557 DISCLOSURES: No relevant relationships by Roger Alvarez, value=Travel Removed 03/30/2022 by Roger Alvarez No relevant relationships by Roger Alvarez, value=Consulting fee Removed 03/30/2022 by Roger Alvarez no disclosure on file for Michelle Hernandez;No relevant relationships by Rose Puthumana

CARDIAC TAMPONADE AS A DEADLY COMPLICATION OF TENSION PNEUMOPERICARDIUM: A CASE REPORT

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Pneumopericardium is the presence of air or gas in the pericardial space, usually secondary to blunt or penetrating trauma. Most pneumopericardium are non-tension. The use of positive pressure ventilation (PPV) increases the chances of developing a tension pneumopericardium. We report the case of a 22-year-old male patient admitted for COVID-19 pneumonia who developed pneumopericardium with cardiac tamponade features. CASE PRESENTATION: A 22-year-old male was admitted for acute respiratory distress syndrome due to COVID-19 pneumonia and required intubation on hospital day 10. The next day, he became febrile with new leukocytosis. A chest x-ray showed new extensive pneumomediastinum and pneumopericardium. Vasopressor support and broad-spectrum antibiotics were started for septic shock, however he continued to decompensate rapidly, requiring maximal medical support. His arterial line waveform showed pulsus paradoxus, leading to concern for underlying tension pneumopericardium. Bedside echo was unrevealing as imaging was obstructed by the air in pericardial sac. The patient was too unstable for a CT scan of the chest. After extensive discussion with his family, he was placed on palliative measures only and expired. DISCUSSION: Pneumopericardium is due to an abnormal connection between the pericardial space and a source of air or gas. Levin and Macklin describe three main mechanisms by which this connection can be made. The first: acute rises in alveolar pressure and volume or ventilator associated lung injury leading to rupture of alveoli with gas tracking along perivascular and peri bronchial sheaths to the mediastinum. The second: macro-perforation of the pericardial space leading to communication with respiratory or gastrointestinal tracts. Third: existence of a pneumothorax in the presence of traumatic pericardial tear or congenital pleuro-pericardial connection. Spontaneous pneumopericardium without any anatomic connection is rare and is due to a direct extension of infectious etiologies of the lungs or by an infection of the pericardial space with gas forming bacteria. A tension pneumopericardium causing cardiac tamponade can develop from pneumopericardium with PPV where the pericardial sac acts as a shutter valve letting air in but not out as has been reported sparingly in the literature. Cummings et al described 93 patients who developed tamponade out of 252 patients with pneumopericardium. Our patient possibly developed a pleuro-pericardial tract secondary to his pneumonia. With continued PPV his simple pneumopericardium likely developed into a tension pneumopericardium evidenced by arterial waveforms consistent with pulsus paradoxus, worsening hypotension despite maximal vasopressor support and development of ventricular tachycardia. CONCLUSIONS: Our case highlights the importance of considering pneumopericardium causing cardiac tamponade in the setting of mechanical ventilation. Reference #1: Mindaye ET, Arayia A, Tufa TH, Bekele M. Iatrogenic pneumopericardium after tube thoracostomy: A case report. Vol. 76, International journal of surgery case reports. 2020. p. 259–62. Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984 Jun;37(6):511–8. Reference #3: Levin AI, Visser F, Mattheyse F, Coetzee A. Tension pneumopericardium during positive-pressure ventilation leading to cardiac arrest. J Cardiothorac Vasc Anesth. 2008 Dec;22(6):879–82. MACKLIN CC. TRANSPORT OF AIR ALONG SHEATHS OF PULMONIC BLOOD VESSELS FROM ALVEOLI TO MEDIASTINUM: CLINICAL IMPLICATIONS. Arch Intern Med [Internet]. 1939 Nov 1;64(5):913–26. Available from: https://doi.org/10.1001/archinte.1939.00190050019003 DISCLOSURES: No relevant relationships by Aarti Mittal No relevant relationships by Beenish Naqvi

Macklin Effect in the Current Pandemic: A Pathological Sequelae or Ventilator-Associated Lung Injury

Aim and background: SARS-CoV-2 pandemic questioned many basic concepts in medicine. COVID-19 affects many organ systems despite the lung being the primary affected organ. ARDS management is challenging and a new complication during the management adds to the burden. Macklin described a pathophysiological process by which air escaped through the ruptured alveolar basement membrane causing pneumomediastinum. The occurrence of air leak syndromes (ALS) in COVID-19 made us investigate the disease and its association with the complication. Objective: To observe the clinicopathological profile of patients who developed air leak syndrome during the second wave of the pandemic. Materials and methods: A retrospective analysis was conducted on SARSCoV- 2 patients admitted to ICU due to ARDS. The study included patients admitted from March to June 2021 with rTPCR positive test for SARS-CoV-2 illness and diagnosed to have ARDS as defined by the Berlin criteria. We analyzed 195 cases admitted in the ICU who met the above criteria and received protocolised care as per national and institutional guidelines. Cases who received ventilatory support either as HFNO (high flow nasal oxygenation), NIV (noninvasive ventilation), or invasive mechanical ventilation as per ARDS NET protocol and developed ALS were included. Demographic and clinical profiles of patients and laboratory parameters like acute phase reactants, haemogram, and serum creatinine were analysed. Results: 5.6% of patients were diagnosed to have air leak syndrome, which includes subcutaneous emphysema, pneumomediastinum, pneumopericardium, and pneumothorax. 81% of the cases were men. The average age was 44.8 years. 90% of the patients had no pre-existing lung pathology or respiratory comorbidity. 81.8% did not have a documented history of smoking. 63.33% of patients had other preexisting co-morbidities. 27.2% of patients had more than one comorbidity with diabetes mellitus being the most common. The average time to develop air leak syndrome was 6 days. 81% of the patients received mechanical ventilation, 2 patients were only on HFNO. 90% of the patients were prone in view of severe ARDS. From air leak syndromes mentioned above, 72.2% developed pneumothorax, 63.3% of the patients developed subcutaneous emphysema, 54.5% of the patients developed pneumomediastinum, and 9% developed pneumopericardium. 1 patient (9%) developed the complete spectrum of ALS. 63% of the patients developed 2 or more entities of the air leak, i.e., subcutaneous emphysema, pneumomediastinum, pneumopericardium, and pneumothorax. Acute phase reactants were elevated in all patients who developed ALS. There was neutrophil predominance in the haemogram. Only one patient developed AKI. Another compelling finding was the development of secondary infection, the majority was respiratory tract infections (81%) followed by urinary tract infections. Candiduria was observed in 36.6% of patients. The average duration of stay was 21.6 days. The mortality rate was 63%. 4 patients were discharged who had an average time to resolution of 8 days. Conclusion: COVID-19 is majorly a self-limiting disease. Secondary bacterial infection and poor oxygenation was major finding in our study. Development of ALS in a previously normal lung with no preexisting lung pathology points towards the need to conclude ALS and viral pneumonias.

Pneumomediastinum After COVID-19.

A preadolescent female presented to the emergency department with an acute asthma exacerbation. Chest radiograph and computed tomography scan showed extensive pneumomediastinum with a small pneumopericardium without a distinct source for this air leak. The patient was admitted for noninvasive monitoring, analgesia, and high concentration oxygen. Serial chest radiographs showed marked improvement following high concentration oxygen, and she was discharged on hospital day 3. Spontaneous pneumomediastinum and pneumopericardium are rare complications of asthma that can often be managed conservatively but should be considered on the differential for this patient population, and may be a complication of COVID-19.

Under Pressure: Spontaneous Pneumomediastinum with Resultant Cardiac Tamponade Influencing the Decision to Initiate Extra-Corporeal Membrane Oxygenation

IntroductionWe present a case of a rare but serious adverse consequence of Acute Respiratory Distress Syndrome (ARDS) secondary to COVID-19 infection: spontaneous pneumomediastinum and pneumopericardium resulting in cardiac tamponade. Case descriptionA 35 year old unvaccinated female with a history of degenerative disc disease, Sjogren's disease, and mild persistent asthma presented with COVID-19 pneumonia. On admission, she required near-maximum heated high flow oxygen, yet desaturated with minimal movement. Three days later, she noted sharp chest pain with worsening oxygenation. Chest radiograph revealed diffuse subcutaneous air with concern for bilateral pneumothoraces, and follow up CT revealed pneumomediastinum, pneumopericardium, and extensive subcutaneous emphysema. She was subsequently intubated. She ultimately developed signs of obstructive shock, and an emergent chest CT demonstrated tamponade physiology on the heart from the mediastinal air. Bedside echocardiogram was unable to be performed due to air surrounding the heart. At this time, her Murray score was 3.8, and discussions began regarding transfer to a referral center for Extracorporeal Membrane Oxygenation (ECMO). Given her tenuous hemodynamics and the prospect of transfer in a low-pressure aircraft, a mediastinotomy tube was placed with a large air leak, tidaling of the tube, and improvement in hemodynamics. On arrival at the ECMO center (Saint Joseph Hospital), her tamponade physiology had improved, but she was requiring progressively higher ventilator pressures due to her severe ARDS. Her extensive pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema would likely only be worsened by higher positive end-expiratory pressures. Due to this complex physiology, she was deemed a VVECMO candidate and was cannulated the day after transfer. Following cannulation, her pneumomediastinum and pneumoperitoneum improved, and eventually her mediastinotomy tube no longer demonstrated an air leak or tidaling. As such, it was removed and her hemodynamics remained stable with no evidence of recurrent tamponade. DiscussionThis presented a unique case in which the choice for VVECMO was influenced not only by severity of ARDS, but also by the complicating factor of positive pressure ventilation causing worsening tamponade physiology due to spontaneous tension pneumomediastinum. Additionally, this case adds to the reports of spontaneous pneumomediastinum in COVID-19 infection, as our patient had no history of trauma or barotrauma before this occurred. On literature review, we have only found one other case report in which a tension pneumomediastinum in COVID-19 required bedside mediastinotomy. Physicians should be aware of this potentially fatal complication and expedite referral to an ECMO center.

Air in the Wrong Place at the Wrong Time: A Case of Pneumomediastinum and Pneumopericardium in the Setting of COVID-19 Disease.

Infection with SARS-CoV-2, commonly referred to as COVID-19 disease, has been noted to involve a systemic inflammatory reaction affecting multiple organ systems. Patients present with a spectrum of symptoms from mild to severe respiratory distress requiring supplemental oxygen and, at times, intubation and mechanical intubation. Pulmonary involvement causes diffuse alveolar wall damage leading to destruction and collapse of the alveolar walls causing air leakage and introduction of the air into the mediastinum, pericardium, and interstitial spaces. We present a case of a 71-year-old patient who presented with respiratory distress requiring supplemental oxygen with subsequent rapid decline and decompensation requiring intubation and mechanical ventilation who was found to have pneumomediastinum and pneumopericardium.

A Rare Complication of Pneumopericardium, Spontaneous Pneumothorax, and Subcutaneous Emphysema in a COVID-19 Pneumonia Patient Treated With High Flow Nasal Cannula.

Spontaneous pneumomediastinum (SPM), unrelated to mechanical ventilation, has been newly described as a complication of patients with coronavirus disease (COVID-19) pneumonia without the associated risk factors. The main objective of presenting this case is to highlight a rare but important complication among patients with COVID-19 pneumonia treated only with a high-flow nasal cannula (HFNC). We aim to study the possible underlying pathophysiology of this phenomenon.

A Very Rare Case of Isolated Spontaneous Pneumopericardium Secondary to COVID-19.

Coronavirus disease 2019(COVID-19) is currently a pandemic. In addition to respiratory symptoms, involvement of other organs such as the pericardium is also seen. Pneumomediastinum in COVID-19 patients has rarely been reported. Isolated pneumopericardium without pneumomediastinum is even more uncommon. We described a case of COVID-19 in association with pneumopericardium. To the best of our knowledge, no case with isolated pneumopericardium has been reported thus far.

Isolated Pneumopericardium: A Rare Complication Secondary to COVID-19 Infection.

Pneumopericardium in the setting of COVID-19 is a rare incident. Typically, COVID-19 manifests with respiratory failure, cytokine storm, and gastrointestinal and cardiac symptoms. Chest X-ray (CXR) shows patchy peripheral opacities in bilateral lung fields and computed tomography (CT) shows multifocal ground-glass opacities in a COVID-19 patient. However, CXR is relatively less specific when compared to CT. In this case report, we present a case of isolated pneumopericardium (without pneumomediastinum) in a young female patient with COVID-19 pneumonia. Not only is the mechanism of development of pneumopericardium in COVID-19 patients poorly understood, but it is also considered a bad prognostic factor that leads to mortality.

HYPERSENSITIVITY PNEUMONITIS OR EVALI? A CASE OF ACUTE RESPIRATORY FAILURE IN AN ADOLESCENT

Introduction: Hypersensitivity pneumonitis is an interstitial lung disease caused by lymphocytic response to inhalant exposures such as molds or avian excreta. Given its complexity and variation in presentation, the diagnosis of hypersensitivity pneumonitis requires obtaining a detailed exposure history and thorough workup. Case Description: A 17-year-old previously healthy female without asthma history developed cough, fever, and shortness of breath. A week later, she was intubated for acute respiratory failure. Her initial imaging revealed pneumomediastinum and pneumopericardium with ground glass opacities. The etiology of her respiratory failure remained unclear. Infectious workup, including multiple COVID tests, was negative. Given that she cares for horses, a hypersensitivity pneumonitis panel was done and revealed elevated aspergillus fumigatus IgG level >200 mcg/mL and total IgE of 571 kU/L. BAL showed elevated neutrophil count and lung biopsy was not obtained. She was extubated after a week and subsequently revealed that she vapes marijuana. This introduced e-cigarette and vaping associated lung injury (EVALI) as another etiology for her presentation. She ultimately completed an extended course of steroids and was discharged on supplemental oxygen. Discussion: Our patient presented with acute respiratory failure and negative infectious workup. Initial social history revealed frequent exposure to horse barns, leading to a diagnosis of hypersensitivity pneumonitis. However, it was subsequently revealed that she vaped, which introduced EVALI as another possibility. While her final diagnosis remains nebulous, this case highlights the importance of maintaining a broad differential during assessment of acute respiratory failure and the critical role that astute history taking plays in the diagnostic process. [Formula presented]

Pneumopericardium in a Newborn with Respiratory Distress and COVID-19

BACKGROUND: Pneumopericardium (PPC) is one of the rarest pulmonary air leak syndromes, but the incidence is the highest in the neonatal period. Risk factors include premature infants with respiratory distress (RD) syndrome, receiving active resuscitation, meconium aspiration syndrome, and aggressive mechanical ventilation. Several cases have also been reported related to COVID-19. CASE PRESENTATION: We report a case of a female newborn with a birth weight of 3300 grams a COVID-19 confirmed 35-year-old G3P2A0 mother. The baby was not crying at born and the amniotic fluid was stained green. The baby experienced RD and was intubated. A babygram was performed at the age of 5 h with the impression of a too deep endotracheal tube, neonatal pneumonia, and PPC. COVID-19 RT-PCR examination of the baby was positive. There were no signs of cardiac tamponade, so it was decided to take conservative and supportive management. CONCLUSION: Resolution of PPC was found on repeated babygram 26 h later. The baby was then discharged after 19 days of treatment.

Spectrum of pneumothorax/pneumomediastinum in patients with coronavirus disease 2019.

BACKGROUND: Spontaneous pneumothorax/pneumomediastinum is an uncommon complication of coronavirus disease 2019 (COVID-19). Herein, we describe the clinical spectrum and outcomes of COVID-19-associated pneumothorax/pneumomediastinum in critical care settings. MATERIALS AND METHODS: We hereby present a case series of 12 patients who tested positive for COVID-19 and developed air leak injuries in critical care settings in a tertiary care center in Northern India. Infection with severe acute respiratory syndrome coronavirus-2 was confirmed by nasal/oropharyngeal swab testing using real-time reverse-transcription polymerase chain reaction test. The clinical spectrum and outcomes of these patients were assessed. Each case has been presented as a brief synopsis. RESULTS: The onset of pneumothorax/pneumomediastinum varied from 11 to 28 days after the occurrence of initial symptoms and caused worsening of respiratory parameters in most patients. Of the 12 patients, eight were males who developed air leak injuries. One patient was a current smoker, and three patients had underlying lung disorders. Two patients with spontaneous breathing were managed conservatively. All intubated patients who developed air leak injuries died (100% mortality rate). CONCLUSION: Pneumothorax/pneumomediastinum is a rare and life-threatening complication in mechanically ventilated patients with COVID-19. Further research is needed to understand the pathophysiology behind the development of air leak injuries in patients with COVID-19.

Asymptomatic Spontaneous Pneumopericardium, Pneumomediastinum, and Subcutaneous Emphysema: A Case Report of an Incidental Rare Presentation.

Pneumopericardium (PP), pneumomediastinum (PM), epidural pneumatosis, and subcutaneous emphysema (SE) are identified by the existence of free air or gas in the associated spaces. They are normally self-limited unless tension pneumothorax, tension PM, cardiac herniation, air tamponade, and esophageal rupture accompany these disorders. PM and PP can be divided into "spontaneous" or "secondary" based on the preceding etiologies. Spontaneous PM is often extremely rare and benign in course. On the other hand, secondary PM and PP are more common and result from intrathoracic infections, trauma-related esophageal rupture, or tears along the tracheobronchial tree. Our patient presented four days after a fall from a chair and was found to have suffered a stroke, with complete left side paralysis. CT imaging on arrival was significant for PM, PP, and SE, the cause of which remains unclear. The patient was diagnosed with COVID-pneumonia approximately six months prior to presentation. As the COVID-19 pandemic has evolved, several scientific papers have been published reporting infected patients who had developed spontaneous PT, PM, or even PP, in the absence of invasive mechanical ventilation. Is it possible that the spontaneous findings in our patient were COVID-related? Or could the spontaneous PP, PM, and SE be a sequel to the trauma of her fall from a chair? The answer still remains unclear.

Pulmonary barotrauma in COVID-19: A systematic review and meta-analysis.

BACKGROUND: An ever-increasing number of studies have reported an increased incidence of spontaneous pulmonary barotrauma such as pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients with COVID-19. We conducted this systematic review and meta-analysis to assess the value and significance of the available data. METHODS: A thorough systematic search was conducted to identify studies of barotrauma in hospitalized patients with COVID-19. Data analysis of case reports was done using a statistical package for the social sciences (SPSS) version 22, and meta-analysis was performed using CMA-3. RESULTS: We identified a total of 4488 studies after thorough database searching.118 case reports and series, and 15 observational studies were included in the qualitative analysis. Fifteen studies were included in the quantitative analysis. The observational studies reported barotrauma in 4.2% (2.4-7.3%) among hospitalized patients; 15.6% (11-21.8%) among critically ill patients; and 18.4% (13-25.3%) in patients receiving invasive mechanical ventilation, showing a linear relationship of barotrauma with the severity of the disease. In addition, barotrauma was associated with a longer length of hospital stay, more extended ICU stay, and higher in-hospital mortality. Also, a slightly higher odds of barotrauma was seen in COVID-19 ARDS compared with non-COVID-19 ARDS. CONCLUSION: COVID-19 pneumonia is associated with a higher incidence of barotrauma. It presents unique challenges for invasive and non-invasive ventilation management. Further studies are required to unravel the underlying pathophysiology and develop safer management strategies.