Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

Incidence of barotrauma in an intensive care unit: new data from COVID-19?

Introduction: During COVID-19 pandemic, the massive use of ventilatory support made its complications even more common. This study aimed to analyse the incidence of barotrauma in COVID-19 patients as well as its consequences. Method(s): Retrospective cohort study. All patients undergoing mechanical ventilation in an intensive care unit (ICU) during 2020- 2021 were included. The time of both noninvasive and invasive ventilation was considered together. Statistical analysis was performed using IBM SPSS Statistics 28.0. Result(s): A total of 967 patients were included, with 42 cases of barotrauma being reported (28 men and 14 women, median age 69 years [interval 22-94] and median APACHE 13). Out of those, 40 had severe COVID-19. Regarding patients with and without COVID-19, the incidence of barotrauma (episodes/1000 days of ventilation) was 0.64 and 9.22 (RR 14.86, p < 0.001) and the barotrauma rate (episodes/number of patients) was 0.4% and 8.5% (RR 21.25, p < 0.001), respectively. The most common type of barotrauma was subcutaneous emphysema (52.4%, CI 95% 37.3-67.5%), followed by pneumomediastinum (47.6%, CI 95% 32.5-62.7%) and pneumothorax (35.7%, IC 95% 21.2-50.2%). The median time to diagnosis was 11.5 days after initiation of ventilatory support [interval 1-67]. In the COVID-19 group, barotrauma was associated with longer ventilation (14.06 vs 7.91 days, p < 0.001), longer ICU stay (16.74 vs 8.17 days, p < 0.001) e higher mortality rates (45.0% vs 26.2%, RR 1.72, p 0.011). Conclusion(s): We found a higher susceptibility to developing barotrauma as a potential complication of COVID-19 patients undergoing mechanical ventilation. From those, subcutaneous emphysema and pneumomediastinum seem to be more prevalent than pneumothorax. Barotrauma seems to be associated with longer periods undergoing mechanical ventilation, longer ICU stays and higher hospital mortality rates.

Incidence and outcomes following pulmonary barotrauma in COVID-19 ventilated and non-ventilated patients with acute respiratory failure: A retrospective study.

Background and Objectives: : Alveolar rupture following increased transalveolar pressure on positive pressure ventilation is associated with pulmonary barotrauma (PB). The spectrum varies from pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, retro-pneumoperitoneum and subcutaneous emphysema. We studied the incidence of PB and their clinical characteristics in patients with coronavirus disease 19 (COVID-19)-associated acute respiratory failure. Methods: Patients aged >18 years with COVID-19-associated acute respiratory distress syndrome were included in the study. We recorded demographics (age, gender, comorbidities), severity scores (APACHE II on admission, SOFA on the day of barotrauma), type of PB and outcomes at discharge from the hospital. Patient characteristics are descriptively reported. Survival analysis was done using Kaplan-Meier survival tests after classifying by various factors. Survival was compared using the log-rank test. Results: Thirty-five patients experienced PB. Eighty per cent of patients in this cohort were males with mean age of 55.89 years. The commonest comorbidities were diabetes mellitus and hypertension. Twelve spontaneously breathing patients developed barotrauma. Eight patients experienced sequential events. In all, 18 patients required insertion of pigtail catheters. The median survival time in patients was 37 days (95% CI: 25-49 days). The overall survival rate was 34.3%. Mean serum ferritin levels were six times upper limit of normal in deceased, reflecting the severity of lung involvement. Conclusion: A high incidence of PB was noted following severe acute respiratory syndrome coronavirus (SARS CoV-2) infection even in the non-ventilated patients, a consequence of SARS CoV-2 effects on the pulmonary parenchyma causing widespread lung injury.

Mediastinal Pigtail Catheterization for Treatment of Pneumomediastinum in a COVID-19 Patient: A Case Report

Spontaneous pneumomediastinum (SPM) is a decisive complication reported to be associated with COVID-19. Here, we present a case of SPM in a COVID-19positive patient that was not caused by any iatrogenic or known reasons. At the time of admission, the patient was COVID-positive and distressed. He was immediately subjected to hematological and radiological investigations (chest X-ray, HRCT), which confirmed pneumomediastinum. The patient was hypoxic and hypotensive even after receiving ionotropic support. Considering the patient's critical condition, a mediastinal pigtail catheterization was performed instead of a thoracotomy, and the catheter was in situ for nine days. Arterial blood gas was monitored during the hospital stay, and supplementary oxygen therapy was provided accordingly. The patient subsequently recovered and was discharged. Hence, SPM in this COVID patient was treated by pigtail catheterization, and major surgical interventions were avoided.Copyright © 2023 LookUs Scientific. All rights reserved.

Pneumomediastinum (PM) as a complication of COVID-19 disease

Case report Introduction: PM is a rare, but potentially life-threatening complication during COVID 19 pandemic, being reported in patients affected by COVID-19 pneumonia, even in the absence of mechanical ventilation-related barotrauma. Case details: We reported the clinical data of 4 cases affected by COVID-19 pneumonia complicated with PM. Chest CT scan showed multiple confluent areas of ground-glass opacities, crazy paving pattern, PM, cervical subcutaneous emphysema, and pneumothorax in one case. Management included pharmacological treatment, oxygen supplementation and no acute intervention recommended by cardiothoracic surgery. Case 1: 50-year- old male without past medical history, non-smoker, hypoxic on the day of admission. During the hospital stay, he continued to require increasing levels of oxygen and was subsequently flown to a tertiary care center for higher level of care. Case 2: 38-year- old male admitted with a 7-day history of fever, dyspnea and cought. He continues to be symptomatic with neurological manifestations (COVID19 Encephalopathy). Finally whose dyspnea regressed during hospitalization, he was discharged at his own request to come for control. Case 3: 73-year- old male with a history of hypertension, non-smoker, presented with complaints of shortness of breath for 1 week. He did not receive non invasive positive pressure ventilation. The pneumothorax and PM were managed conservatively. Case 4: 53-year- old lady with no significant past medical history, presented with fever and cough for 10 days and worsening shortness of breath for two days. Progressive deterioration of respiratory function transferred her to the intensive care unit. In view of worsening hypoxia and increased work of breathing, she was intubated on the same day and was started on volume control ventilator support. Despite the support measures she developed multiple organ failure and passed 35 days after the symptoms initiated. Conclusion(s): PM is usually self-limiting and is managed conservatively. Treatment of the underlying causes and least damaging ventilator settings possible to achieve adequate oxygenation are the mainstays in managing PM. COVID-19 patients with PM seem to have a more complicated clinical course and poor outcome.

Dermatological manifestations associated with the severity of COVID-19 infection: A retrospective cross-sectional observational study in 144 patients

Introduction: COVID-19 infection is a disease caused by the type 2 coronavirus that causes severe acute respiratory syndrome (SARS-CoV-2) that affects the respiratory mucosa and all those organs that present the type 2 angiotensin receptor (ACE2), within them the skin. Several authors have mentioned the importance of reporting and carrying out databases on skin lesions caused by this virus, since it is related to the detection, severity and prognosis of the systemic condition. Material(s) and Method(s): A retrospective cross-sectional observational study was carried out on the cases of patients who presented dermatological manifestations due to COVID-19, registered in the physical database of the National Specialized Hospital of Villa Nueva, Guatemala, from January 1st to December 31, 2021. Result(s): A total of 144 patients presented dermatological manifestations due to COVID-19, which were: acral lesions (42%), rash (21%), subcutaneous emphysema (12%), oral mucosal lesions (7%), necrosis (6%), erythema multiforme (5%), telogen effluvium (2%), vesicular lesions (2%), urticaria (1%), pityriasis rosea Gibert (1%) and livedo-type lesion (1%). A statistically significant association (p = 0,00) was found in patients who presented dermatological manifestations with vasculonecrotic damage as they were more likely to suffer from severe to critical disease (OR 2,91;95% CI 1063-3083). Conclusion(s): Early identification of cutaneous semiology is essential for timely management of complications associated with COVID-19 disease.Copyright © 2022 Elsevier Espana, S.L.U.

A Case of Pneumothorax Ex Vacuo Associated with COVID-19.

Pneumothorax is a known complication of coronavirus disease 2019 (COVID-19). The concept of pneumothorax ex vacuo has also been proposed to describe pneumothorax that occurs after malignant pleural effusion drainage. Herein, we present the case of a 67-year-old woman who had abdominal distension for 2 months. A detailed examination led to the suspicion of an ovarian tumor and revealed an accumulation of pleural effusion and ascitic fluid. Thoracentesis was performed, raising the suspicion of metastasis of high-grade serous carcinoma arising from the ovary. An ovarian biopsy was scheduled to select subsequent pharmacotherapy, and a drain was inserted preoperatively into the left thoracic cavity. Thereafter, a polymerase chain reaction analysis revealed that the patient was positive for COVID-19. Thus, the surgery was postponed. After the thoracic cavity drain was removed, pneumothorax occurred, and mediastinal and subcutaneous emphysema was observed. Thoracic cavity drains were then placed again. The patient's condition was conservatively relieved without surgery. This patient may have developed pneumothorax ex vacuo during the course of a COVID-19 infection. Since chronic inflammation in the thoracic cavity is involved in the onset of pneumothorax ex vacuo, careful consideration is required for the thoracic cavity drainage of malignant pleural effusion and other fluid retention.

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.

Pneumomediastinum in COVID-19 critically ill patients

Pneumomediastinum in COVID-19 critically ill patients Introduction: Pneumomedisatinum(PM) is an uncommon potentially life-threatening complication of COVID-19 and can be an aggravating factor. This study aimed to determine the incidence and outcomes of PM in critically ill COVI19 patients. Method(s): A retrospective study carried out in a 9-bed intensive care unit from October 1st, 2020 to February 28, 2021 including patients with confirmed COVID19 related acute respiratory distress syndrome (ARDS) with confirmed PM on Chest computed tomography (CT). Were recorded patients characteristics, management and outcomes. Result(s): 7 cases of PM were reported : 5 men, 2 women, aged between 47 and 70 years-old. None of them had underlying lung disease. 4 patients were under invasive mechanical ventilation (IMV), 2 under non-invasive ventilation (NIV) and one had a spontaneous PM at the time of the event. Chest CT scan showed : pulmonary involvement, moderate (n=4/7) to severe (n=3/7), PM (n=7/7), subcutaneous emphysema (n=5/7) and pneumothorax (n=2/7). The highest positive end-expiratory pressure (PEEP) for patients receiving IMV and NIV were respectively 10cmH2O and 6cmH2O. Urgent mediastinal decompression wasn't immediately indicated, conservative therapy with reduced airway pressure was adopted. Patients with NIV were intubated after NIV failure. Despite protective ventilation with lower pressure, needle aspiration and chest drainage, all patients expired during their hospital stay. Conclusion(s): Our findings suggest that PM is secondary to inflammatory response due to COVID-19 and mostly triggered by the use of positive pressure ventilation and it is associated with poor outcome in critically ill COVID-19 patients.

Pneumothorax in Patients with COVID-19 in Tertiary Intensive Care

Objectives: Objective of the study was to examine the laboratory findings with clinical characteristics and treatments of patients who were hospitalized in a tertiary intensive care unit with the diagnosis of coronavirus disease 2019 (COVID-19) and developed pneumothorax and to determine epidemiology and risks of pneumothorax. Method(s): The study was conducted by retrospectively examining the electronic records of 681 COVID-19 patients who were followed up between 1 April 2020 and 1 January 2021 in 3 tertiary intensive care units (each was 24 beds). Patients demographic and clinical characteristics, laboratory findings, mechanical ventilator parameters and chest imaging were evaluated retrospectively. Result(s): Pneumothorax in 22 (3.2%) of 681 with COVID-19 patients was detected and acute respiratory distress syndrome (ARDS) in 481 (70.6). All the study patients met ARDS diagnostic criterias. Mortality rates were 43.4% (296/681) in all patients, 52.8% (254/481) in patients with ARDS, and 86.3% (19/22) in patients with pneumothorax. Pneumothorax occurred in the patients within a mean of 17.4+/-4.8 days. The computed tomographies of patients were observed common ground-glass opacities, heterogenic distribution with patch infiltrates, alveolar exudates, interstitial thickening in the 1st week of their symptom onset. Conclusion(s): We observed that pneumothorax significantly increased mortality in COVID-19 patients with ARDS. We believe that understanding and preventing the characteristics of pneumothorax will make an important contribution to mortality reduction.Copyright © 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.

The successful use of Pezzer Catheter in Covid-19 patients

Introduction: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was often during the pandemic era. Over 3500 patients were treated in our hospital and approximately 400 required mechanical ventilation and presented pneumothorax due to barotrauma. We present our experience in cases of recurrent or loculated pneumothoraces in Covid-19 patients treated successfully with the use of Pezzer catheter. Material(s) and Method(s): Cases were collected retrospectively based on author recall. Ninety-one intubated patients ranging in age from 65 to 78 years presented with pneumothoraces. A 28 French Argyle intercostal catheter was inserted initially, resulting in re-expansion. Despite the above treatment 41 patients (45%) were unstable with recurrent or loculated pneumothoraces and one found hard to ventilate them. So, a Pezzer catheter made of Latex was placed at the site of the loculated pneumothorax. Result(s): All pneumothoraces were resolved within 3 days after the insertion of a Pezzer catheter and the subcutaneous emphysema decreased significantly. There were no major complications recorded. Conclusion(s): 1. It is well known that the most basic issue that may have an impact on airleaks is chest tube management. That is the reason we concentrated on the type and position of chest drain. 2. Our experience supports the use of Pezzer catheter connected to water seal in cases of persistent pneumothorax with prolonged air leak and increasing subcutaneous emphysema, since it promotes pleurodesis, reduces significantly the duration of the intrapleural drainages and the length of the in-hospital stay. 3. The procedure is cost-effective, safe, and easy to perform.

Incidence of pneumothorax, subcutaneous emphysema and pneumomediastinum in patients with COVID - 19

Introduction: Pneumomediastinum, subcutaneous emphysema and pneumothorax are uncommon conditions in which air is trapped in the mediastinum, subcutaneous tissues or the pleural cavity with varied etiology. Aim(s): To determine the incidence of these complications in patients with COVID - 19 and whether there is a significant correlation between them and certain demographic markers (age, gender) and mortality. Method(s): A retrospective analysis of 2197 patients who were admitted to the Department of Pneumonology and its Respiratory Intensive Care Unit (RICU) in the period between June 2020 and January 2022 was performed. A total number of 72 patients were identified in which the presence of one or more of these conditions was confirmed via imaging studies. Data about demographics (age, gender), the necessity for O2 supplementation or ventilation and disease outcome was gathered and analyzed. Result(s): Out of the 72 patients 41 (56.9%) were females and 31 (43.1%) males, the mean age was 63.83 +/- 13.3. Pneumomediastinum was observed in 47 patients (2.13% of the total population), 85.1% (n = 40) mortality was observed, no statistically significant correlation was found. Subcutaneous emphysema was documented in 58 patients (2.63%) of which 53 (91.4%) died, no significant correlation was found. Pneumothorax was diagnosed in 14 (0.63%) patients, the mortality was 78.6% (n = 11) and a moderate and statistically significant correlation between pneumothorax and the male gender was found. Conclusion(s): At the current time there is little data confirming significant correlations between the analyzed variables, but due to the rarity of these complications further analysis is warranted.

Clinical Characteristics of COVID-19 between ICU and non-ICU patients

Introduction: During the peak of COVID-19 crisis between May and September 2021, Hospital UiTM Sg. Buloh was converted to a full COVID-19 hospital. We described our experience in managing active COVID-19 patients and subsequent follow-ups. Result(s): 215 COVID-19 patients were admitted to Hospital UiTM Sg Buloh between May and September 2021;81 patients (38%) required ICU admission, and 134 patients (62%) required only ward admission. Mean age was 53 years old, male 61%, mean day of illness at presentation was 9 days, and mean duration of hospital admission was 10 days. Fully vaccinated patients were less likely to be admitted to ICU, OR 0.2 (0.04 - 0.89). ICU patients were more likely to be female Adj OR 2.0 (1.11-3.56), diabetic Adj OR 1.9 (1.04-3.68), have more extended hospital stay (17 vs. 6 days), and higher mortality OR 5.50 (2.64-11.34). In terms of laboratory investigations 24 hours prior to oxygen requirement, those required ICU admissions have higher creatinine (167 vs. 107 mmol/L), CRP (115 vs. 69 ug/L), and ALT (80 vs. 53 mmol/L), as well as lower PF ratio (148 vs. 210). Cardiac arrhythmias and secondary infection were more likely in ICU patients, Adj OR 16.44 (1.56-172.81) and 12.05 (5.44-26.69), respectively. While pneumothorax, pneumomediastinum, subcutaneous emphysema, and acute cor-pulmonale were only observed in ICU patients. Mortality was recorded in 43 cases (20%). 83 patients out of 172 COVID-19 survivors (48%) attended a 3-month follow-up which revealed no difference in symptoms, 6-minute-walk-tests, and spirometry between ICU and non-ICU patients. Conclusion(s): ICU COVID-19 patients have poorer outcomes during hospital admission but similar recovery with nonICU patients at 3-month follow-up.

Evaluation of risk factors for barotrauma complications in COVID-19 patients treated with high flow nasal cannula (HFNC)

Aim: To evaluate risk factors for barotrauma development in COVID-19 patients treated with HFNC. Method(s): 34 COVID-19 patients are studied retrospectively, 24 males, mean age 61,74 years. Symptoms (dyspnoea, cough, fever, hemoptoe, fatigue), comorbidities (arterial hypertension (AH), COPD, asthma, diabetes, heart and kidney diseases, bronchiectasis), blood tests (total blood count, neutrophils to lymphocytes (Neu:Ly) ratio, lactate dehydrogenase (LDH), ferritin, interleukin-6, C-reactive protein), chest X-ray findings at admission are assessed. Need for oxygen therapy (ambient air, low flow therapy, HFNC) during the hospitalisation, barotrauma development (pneumothorax (PT), pneumomediastinum (PM), subcutaneous emphysema (SE)) and disease outcome are analysed. Result(s): Age decrease by 1 year leads to increased risk of SE by 17% (hazard ratio (HR)0.852,p=0.018). LDH increase by 1 U/l leads to 0.4% increased risk of SE (HR1.004,p=0.020). Age and LDH level are proved as risk factors for SE. AH increases the risk of PM by 27.5% (HR1.275,p=0.087). Ferritin increase by 1 ug/l leads to 0.2% higher risk of PT (HR1.002,p=0.019). Multivariate model reveals AH (HR1.777,p=0.057) and ferritin level (HR1.004,p=0.013) as risk factors for barotrauma. Multivariate model shows LDH (HR1,003,p=0,023), ferritin (HR1,004,p=0,007), and Neu:Ly (HR1,123,p=0,059) as main risk factors for PT,PM, SE. Dyspnoea increases the death risk 11 times (HR11.2,p=0.034) while LDH increase by 1 U/l leads to 0.1% increased death risk (HR1.001,p=0.087). Conclusion(s): AH, age, ferritin, LDH, Neu:Ly levels are proved as risk factors for PT, PM and SE. Dyspnoea is a risk factor for death outcome.

Mysterious Cause of Tracheal Damage in Patients with Covid -19 on Mechanical Ventilation

Introduction: Tracheomegaly (TM) is a very rare and often unrecognized phenomenon defined radiologically as an abnormal enlargement of the diameter of the trachea exceeding 21 mm in women and 25 mm in men. In most cases it is congenital, while possible causes of acquired TM include diseases of the connective tissue (Mounier-Kuhn and Ehlers-Danlos syndrome), various inflammatory conditions (chronic bronchitis, pulmonary and cystic fibrosis), smoking, and prolonged mechanical ventilation with increased cuff pressure. There are few papers in the literature addressing TM, mainly case reports and some case series. Material(s) and Method(s): We retrospectively analyzed chest x-rays of all patients who were mechanically ventilated from April 1, 2020, to January 31, 2021. The occurrence of TM was determined by measuring the diameter of the trachea before intubation and by continuously measuring the diameter of the trachea in the cuff area after intubation, from which we calculated the cuff-to-trachea diameter ratio (C/T ratio). Result(s): The study included 1015 patients divided into three groups: 383 patients treated in the intensive care unit with mechanical ventilation, 132 patients treated with high-flow oxygen ventilation, and 500 randomly selected patients treated with nasal catheter oxygen therapy. Among the patients studied, we observed radiologically visible TM in the cuff area in 18.54% of patients, whereas the percentage of TM in patients with prolonged MV was 90.6%. A C/T ratio >1.5 was observed in 12.53% of patients. Respiratory complications, a total of 16.71% of them (pneumomediastinum, pneumothorax, tracheoesophageal fistula, subcutaneous emphysema, tracheomalacia) showed a significant association with C/T ratio. Using ROC analysis, C/T ratio is considered a reliable potential prognostic factor for respiratory complications. Conclusion(s): The results of our study demonstrate the importance of early detection and prevention of TM in MV patients with COVID-19 by chest X-ray and measurement of C/T ratio and promote understanding of the development of this rare phenomenon.

Incidence of Air Leaks in Critically Ill Patients with Acute Hypoxemic Respiratory Failure Due to COVID-19.

Subcutaneous emphysema, pneumothorax and pneumomediastinum are well-known complications of invasive ventilation in patients with acute hypoxemic respiratory failure. We determined the incidences of air leaks that were visible on available chest images in a cohort of critically ill patients with acute hypoxemic respiratory failure due to coronavirus disease of 2019 (COVID-19) in a single-center cohort in the Netherlands. A total of 712 chest images from 154 patients were re-evaluated by a multidisciplinary team of independent assessors; there was a median of three (2-5) chest radiographs and a median of one (1-2) chest CT scans per patient. The incidences of subcutaneous emphysema, pneumothoraxes and pneumomediastinum present in 13 patients (8.4%) were 4.5%, 4.5%, and 3.9%. The median first day of the presence of an air leak was 18 (2-21) days after arrival in the ICU and 18 (9-22)days after the start of invasive ventilation. We conclude that the incidence of air leaks was high in this cohort of COVID-19 patients, but it was fairly comparable with what was previously reported in patients with acute hypoxemic respiratory failure in the pre-COVID-19 era.

An approach from the neck to drain expanding pneumomediastinum: a case report.

Background: Several methods for draining pneumomediastinum have been advocated, but no consensus has been established. We propose a novel method for draining air from pneumomediastinum. Case Description: We used an approach from the neck to drain pneumomediastinum that had started to compress the heart in a 33-year-old man with coronavirus disease 2019 (COVID-19) on mechanical ventilation. Computed tomography showed extension of pneumomediastinum to the lateral and dorsal aspects of the right sternocleidomastoid muscle, presenting as subcutaneous emphysema at the neck. We made a 4-cm incision lateral to the right sternocleidomastoid muscle. After incising the platysma muscle, the dorsal side of the sternocleidomastoid muscle was easily stripped off due to the presence of air, allowing placement of a 14-Fr Nelaton catheter. Subcutaneous emphysema as well as pneumopericardium on X-rays improved and disappeared by 3 days after starting drainage. Positive end-expiratory pressure (PEEP) was titrated in a stepwise manner from 6 to 10 cmH2O, with no re-appearance of subcutaneous emphysema. The Nelaton catheter at the neck was removed and the skin was sutured using 3-0 Nylon monofilament. Conclusions: We propose this approach from the neck to release air and prevent deterioration of pneumomediastinum communicating with subcutaneous emphysema at the neck.