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1.
Eur J Med Res ; 27(1): 218, 2022 Oct 28.
Article in English | MEDLINE | ID: covidwho-2108966

ABSTRACT

PURPOSE: This study aimed to investigate air leakage during invasive mechanical ventilation (IMV) in a pediatric intensive care unit (PICU) and explore potential risk factors. METHODS: We conducted a retrospective cohort study of children who underwent IMV in a single-center PICU in a tertiary referral hospital. Air leakage risk factors and factors associated with an improved outcome were assessed. RESULTS: A total of 548 children who underwent IMV were enrolled in this study. Air leakage occurred in 7.5% (41/548) of the cases in the PICU. Air leakage increased the duration of IMV and hospitalization time. Multivariate logistic regression analysis showed a higher risk of air leakage during IMV for PICU patients with acute respiratory dyspnea syndrome (ARDS) (OR = 4.38), a higher pediatric critical illness score (PCIS) (OR = 1.08), or a higher peak inspiratory pressure (PIP) (OR = 1.08), whereas the risk was lower for patients with central respiratory failure (OR = 0.14). The logistic model had excellent predictive power for air leakage, with an area under the curve of 0.883 and tenfold cross-validation. Patients aged between 1 and 6 years who were diagnosed with measles or pneumonia and had a low positive end-expiratory pressure (PEEP) or high PaO2/FiO2 ratio were associated with improved outcomes. Patients diagnosed with central respiratory failure or congenital heart diseases were associated with less desirable outcomes. CONCLUSIONS: Patients with ARDS, a higher PCIS at admission or a higher PIP were at higher risk of air leakage.


Subject(s)
Respiratory Distress Syndrome , Respiratory Insufficiency , Child , Humans , Infant , Child, Preschool , Respiration, Artificial/adverse effects , Retrospective Studies , Intensive Care Units, Pediatric , Risk Factors , Respiratory Distress Syndrome/epidemiology , Respiratory Distress Syndrome/therapy , Intensive Care Units
2.
Medicina (Kaunas) ; 58(11)2022 Oct 26.
Article in English | MEDLINE | ID: covidwho-2090278

ABSTRACT

For COVID-19 pneumonia, many manifestations such as fever, dyspnea, dry cough, anosmia and tiredness have been described, but differences have been observed from person to person according to age, pulmonary function, damage and severity. In clinical practice, it has been found that patients with severe forms of infection with COVID-19 develop serious complications, including pneumomediastinum. Although two years have passed since the beginning of the pandemic with the SARS-CoV-2 virus and progress has been made in understanding the pathophysiological mechanisms underlying the COVID-19 infection, there are also unknown factors that contribute to the evolution of the disease and can lead to the emergence some complications. In this case report, we present a patient with COVID-19 infection who developed a massive spontaneous pneumomediastinum and subcutaneous emphysema during hospitalization, with no pre-existing lung pathology and no history of smoking. The patient did not get mechanical ventilation or chest trauma, but the possible cause could be severe alveolar inflammation. The CT results highlighted pneumonia in context with SARS-CoV-2 infection affecting about 50% of the pulmonary area. During hospitalization, lung lesions evolved 80% pulmonary damage associated with pneumomediastinum and subcutaneous emphysema. After three months, the patient completely recovered and the pneumomediastinum fully recovered with the complete disappearance of the lesions. Pneumomediastinum is a severe and rare complication in COVID-19 pneumonia, especially in male patients, without risk factors, and an early diagnosis can increase the chances of survival.


Subject(s)
COVID-19 , Mediastinal Emphysema , Subcutaneous Emphysema , Humans , Male , Mediastinal Emphysema/diagnosis , Mediastinal Emphysema/etiology , COVID-19/complications , SARS-CoV-2 , Tomography, X-Ray Computed/methods , Subcutaneous Emphysema/etiology , Subcutaneous Emphysema/complications
3.
Children (Basel) ; 9(11)2022 Oct 27.
Article in English | MEDLINE | ID: covidwho-2090023

ABSTRACT

Spontaneous pneumomediastinum (SPM) associated with SARS-CoV-2 infection is a rare condition but can represent a medical emergency. It is probably related to alveolar damage secondary to SARS-CoV-2 infection, which allows air to escape in the surrounding lung tissue. Cough and airways' barotrauma are also mentioned as contributing mechanisms. Treatment is generally conservative, but surgery may be required in severe cases. This paper presents the case of a 16-year-old girl with COVID-19-associated SPM who was treated conservatively in our department. The clinical course was favorable with resolution of respiratory symptoms and radiological (chest CT scan) image of pneumomediastinum. The patient was discharged 7 days after the confirmation of the initial SP diagnosis with appropriate treatment and recommendations for isolation. The sudden occurrence of chest pain and dyspnea should raise the suspicion of SPM in COVID-19 patients. Close surveillance and proper radiological monitoring are required in such cases. Treatment should be strictly individualized based on clinical course and radiological appearance.

4.
Acta Anaesthesiologica Belgica ; 72(1):37-43, 2021.
Article in English | Web of Science | ID: covidwho-2081749
5.
Tanaffos ; 20(4): 368-372, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-2073854

ABSTRACT

The novel coronavirus infection is a global health concern in 2020. Computerized tomography (CT) scan has an important role in diagnosis and follow-up with the course of the disease. The most common radiologic findings in patients are bilateral peripheral patchy ground-glass opacities and consolidations. Although in a few cases, as we reported, we encountered some rare manifestations such as pneumothorax, pneumomediastinum, and subcutaneous emphysema, which imply distinct concerns about the management and outcome of the disease. Pulmonary interstitial emphysema develops due to an increase in alveolar pressure or because of alveolar rupture, secondary to alveolar membrane damage by the virus and proceed to such a complication. Therefore, it is crucial to be aware of the complications of novel coronavirus infection in the deterioration of the disease.

6.
Open Access Macedonian Journal of Medical Sciences ; 10:217-221, 2022.
Article in English | EMBASE | ID: covidwho-2066680

ABSTRACT

INTRODUCTION: The first data for COVID-19 in pregnancy showed mild-to-moderate forms of the disease while the current data speak of severe forms in these subjects. Here, we present a case of a severe form of COVID-19 in a gemelar pregnant woman complicated with pneumomediastinum and pneumothorax, during her hospital stay, in a late stage of disease. CASE PRESENTATION: A 38-year-old multiparous woman was referred to university hospital at 25 weeks of gemelar pregnancy. On admission, the patient presented with signs of moderate respiratory insufficiency, which after 12 h progressed further to severe ARDS. She tested positive for SARS-CoV-2 on quantitative real-time polymerase chain reaction. Under these conditions, it was decided that the patient undergoes a cesarean section for termination of pregnancy. Remdesivir 200 mg/day and tocilizumab 8 mg/kg were administered, based on national guidelines. The patient’s fever subsided, but her SpO2 remained at 94%, even with a 15 L/min oxygen mask. After 12 days, the patient complains of a severe back pain and her respiratory condition rapidly worsened and reduced saturations up to 80% being under O2 therapy with facial mask with 15 l/min. Chest CT findings confirmed pneumomediastinum and pneumothorax, which deteriorated the patient’s status. Thereafter, tube thoracostomy was performed. There was a clinical and ABG analysis parameter’s improvement. The patient was discharged 34 days after cesarean delivery with a proper general health. CONCLUSION: Our case highlights even more convincingly the fact that, in pregnancy, can be severe to life-threating forms of COVID-19. Pneumothorax and pneumomediastinum are complications that can be encountered even in the late stages of severe forms cases with COVID-19 in pregnancy. Early diagnosis of these complications is essential in adequate management and treatment to avoid fatal outcome.

7.
Cir Cir ; 90(4): 543-547, 2022.
Article in English | MEDLINE | ID: covidwho-2067554

ABSTRACT

Several alterations that, due to their pathophysiology, are collectively classified as "air leaks", have been rare complications of COVID-19 pneumonia. In the context of infection by SARS-CoV-2, the debate arises as to whether these are classified as spontaneous or secondary, since the multiple mechanisms of pulmonary structural damage that COVID-19 entails condition lung fragility in a patient in short time. For the above, we presents the case of a 36-year-old female patient with COVID-19 complicated with pneumomediastinum and subcutaneous emphysema in order to illustrate and discuss these complications.


Diversas alteraciones que, por su fisiopatología, son clasificadas en conjunto como «fugas de aire¼, han sido complicaciones raras de la neumonía por COVID-19. Respecto a la infección por SARS-CoV-2, se plantea el debate de si estas se clasifican como espontáneas o secundarias, ya que los múltiples mecanismos de daño estructural pulmonar que conlleva la COVID-19 condicionan fragilidad pulmonar en corto lapso. Por lo anterior, se expone el caso de una paciente de 36 años con COVID-19 complicada con neumomediastino y enfisema subcutáneo con el objetivo de ilustrar y discutir dichas complicaciones.


Subject(s)
COVID-19 , Mediastinal Emphysema , Subcutaneous Emphysema , Adult , COVID-19/complications , Female , Humans , Mediastinal Emphysema/etiology , SARS-CoV-2 , Subcutaneous Emphysema/etiology , Tomography, X-Ray Computed/adverse effects
8.
Cir Cir ; 90(4): 540-542, 2022.
Article in English | MEDLINE | ID: covidwho-2067553

ABSTRACT

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.


Subject(s)
COVID-19 , Mediastinal Emphysema , Pneumopericardium , Pneumothorax , COVID-19/complications , Humans , Male , Mediastinal Emphysema/diagnostic imaging , Mediastinal Emphysema/etiology , Middle Aged , Pneumopericardium/complications , Pneumopericardium/etiology , Pneumothorax/etiology , SARS-CoV-2
9.
Biomedicines ; 10(10)2022 Oct 06.
Article in English | MEDLINE | ID: covidwho-2065698

ABSTRACT

COVID-19 has attracted worldwide attention ever since the first case was identified in Wuhan (China) in December 2019 and was classified, at a later time, as a public health emergency of international concern in January 2020 and as a pandemic in March 2020. The interstitial pneumonia caused by COVID-19 often requires mechanical ventilation, which can lead to pulmonary barotrauma. We assessed the relationship between pneumonia severity and the development of barotrauma in COVID-19-positive patients mechanically ventilated in an intensive care unit; we therefore analyzed the prevalence of iatrogenic barotrauma and its trends over time during the pandemic in COVID-19-positive patients undergoing mechanical ventilation compared to COVID-19-negative patients, making a distinction between different types of ventilation (invasive mechanical ventilation vs. noninvasive mechanical ventilation). We compared CT findings of pneumomediastinum and pneumothorax in 104 COVID-19-positive patients hospitalized in an intensive care unit and 101 COVID-19-negative patients undergoing mechanical ventilation in the period between October 2020 and December 2021. The severity of pneumonia was not directly correlated with the development of barotrauma. Furthermore, a higher prevalence of complications due to barotrauma was observed in the group of mechanically ventilated COVID-19-postive patients vs. COVID-19-negative patients. A higher rate of barotrauma was observed in subgroups of COVID-19-positive patients undergoing mechanical ventilation compared to those treated with invasive mechanical ventilation. The prevalence of barotrauma in COVID 19-positive patients showed a decreasing trend over the period under review. CT remains an essential tool in the early detection, diagnosis, and monitoring of the clinical course of SARS-CoV2 pneumonia; in evaluating the disease severity; and in the assessment of iatrogenic complications such as barotrauma pathology.

10.
Chest ; 162(4):A2637, 2022.
Article in English | EMBASE | ID: covidwho-2060976

ABSTRACT

SESSION TITLE: Late Breaking Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: (1) Assess the characteristics of COVID-19 patients who developed pulmonary cysts, bullae, blebs, and pneumatoceles. (2) Investigate outcomes of patients who developed cystic lung disease from COVID-19. METHODS: A literature search using Pubmed, Cochrane, and Embase was performed for case reports from 2020 to 2022 describing COVID-19 patients who developed lung cysts, bullae, blebs and pneumatoceles. The following data were extracted: patient demographics, presence of underlying lung disease, history of smoking, maximum oxygen requirements during acute illness, imaging findings, complications, and patient mortality. RESULTS: 65 publications (11 case series and 54 case reports) with a total sample size of 76 patients were analyzed. The mean age of patients was 52.2 ± 15.8 years. A majority of the cases were males (n=67, 88.2%). Twelve (15.8%) cases had an underlying lung disease, such as COPD or asthma, and 16 (21.1%) cases had a history of smoking tobacco. We categorized severity of illness based on the levels of oxygen requirement defined as: (1) mild - 0 to 2 liters of oxygen, (2) moderate - greater than 2 liters of oxygen to face mask/venturi mask and (3) severe - high flow nasal cannula, non-invasive ventilation, or mechanical ventilation. The majority of patients (n=40, 52.6%) had severe illness while 7 (9.2%) and 17 (22.4%) presented with mild and moderate disease, respectively. Of the 25 (32.9%) patients who required invasive mechanical ventilation, duration of ventilator days was provided for 14 patients, with a median of 40 days (interquartile range=54). Twenty-one (27.6%) patients were found to have cysts on imaging, 26 (34.2%) were found to have bullae, 3 (3.9%) were found to have blebs, 15 (19.7%) were found to have pneumatoceles, and 11 (14.5%) were found to have more than one of the aforementioned findings. A total of 53 (69.7%) patients developed pneumothorax and 12 (15.8%) developed pneumomediastinum. Seventeen (22.4%) patients were on the mechanical ventilator while pulmonary complications occurred. Additionally, 41 (53.9%) required chest tube placement, 16 (21.1%) required surgical intervention including open thoracotomy or video assisted thoracoscopy. A total of 47 (61.8%) cases reported either resolution of symptoms and complications, or improved imaging findings following interventions. The rate of inpatient mortality was 11.8%. CONCLUSIONS: Patients with severe COVID-19 may have a higher risk for developing cystic lung disease, hence, increasing the risk for complications such as pneumothorax and pneumomediastinum. CLINICAL IMPLICATIONS: Patients who had severe COVID-19 may benefit from closer follow up and serial imaging for early detection of cystic lung disease. DISCLOSURES: No relevant relationships by Kavita Batra No relevant relationships by Rajany Dy No relevant relationships by Christina Fanous No relevant relationships by Wilbur Ji No relevant relationships by Max Nguyen No relevant relationships by Omar Sanyurah

11.
Chest ; 162(4):A2478, 2022.
Article in English | EMBASE | ID: covidwho-2060950

ABSTRACT

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pneumomediastinum is the presence of air or other gas in the mediastinum which can be due to trauma related to mechanical ventilation or spontaneous in preexisting lung diseases. Here, we present the case of Covid-19 pneumonia, who developed pneumomediastinum without any trauma or other risk factors. CASE PRESENTATION: A 56-year-old male COVID unvaccinated with a history of essential hypertension presented to the ED with shortness of breath and worsening cough for one week. He was living with his father, who was admitted to the ICU and receiving treatment for COVID pneumonia. The patient appeared to be in respiratory distress. His initial vital signs were temperature of 99.6 F, respiratory rate of 26 breaths per minute, blood pressure 125/71 mm Hg, heart rate 109 beats per minute with a regular rhythm, and oxygen saturation of 50% while he was breathing ambient air. Pulmonary examination revealed use of respiratory accessory muscle and widespread bilateral coarse rhonchi on auscultation. The rest of the physical examination was within normal limits. RT- PCR COVID -19 test was positive. The blood gas analysis reported respiratory alkalosis. Inflammatory markers were elevated: erythrocyte sedimentation rate (35.2 mg/L), C-Reactive Protein (17.70 mg/dL), Ferritin (1108.1 ng/mL), Lactate Dehydrogenase (813 U/L), Lactate (2.4 mg/dL), D-Dimer (35.20 mg/L) and Troponin High Sensitivity-236.6 ng/L. His CBC, electrolytes, and kidney function were normal. Chest X-ray showed Pneumomediastinum with dense basilar predominant consolidation. CT Angio Chest with contrast reported Pneumomediastinum likely from the left central airway source and bilateral dense ground glass consolidation. An echocardiogram showed an ejection fraction of 60-65%, no valvular abnormalities. He was placed on vapotherm(Oxygen 40L/min) with 100% FiO2. He was given Dexamethasone 6mg for ten days, Remdesivir, Barcitinib, and a 7-day course of Azithromycin and Ceftriaxone for community-acquired pneumonia. He was advised to practice prone positioning for 12 hours or more per day. Pulmonology, Infectious Disease, and Cardiology were consulted. Gradually, his oxygen requirement was weaned down and Pneumomediastinum resolved on serial chest x rays. He was discharged on home oxygen in a clinically stable condition. DISCUSSION: Pneumomediastinum in viral pneumonia is rare. The exact mechanism is unknown. Covid-19 pneumonia causes diffuse alveolar wall damage, which might cause air leakage into the mediastinum. The development of pneumomediastinum is an ominous sign in these patients. Fortunately, our patient did not worsen and was weaned off high flow oxygenation requirement. CONCLUSIONS: Few isolated reported cases of pneumomediastinum in a COVID-19 patient have been associated with life-threatening complications. It should be used as a prognostic marker, and close monitoring of these patients is advisable. Reference #1: Damous, S.H.B., dos Santos Junior, J.P., Pezzano, Á.V.A. et al. Pneumomediastinum complicating COVID-19: a case series. Eur J Med Res 26, 114 (2021) DISCLOSURES: No relevant relationships by Saad Ansari No relevant relationships by Akshit Chitkara No relevant relationships by Sudeshna Ghosh No relevant relationships by Femina Patel

12.
Chest ; 162(4):A2245, 2022.
Article in English | EMBASE | ID: covidwho-2060918

ABSTRACT

SESSION TITLE: Systemic Disease with Diffuse Lung Symptoms Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Rapidly progressive interstitial lung disease (RP-ILD) is a rare and potentially fatal manifestation of dermatomyositis (DM) and has considerable impact in terms of the prognosis. CASE PRESENTATION: A 52-year-old male demonstrated DM-typical rash, fever, mialgias, and mild muscle weakness 3 months after asymptomatic COVID-19 infection. Two weeks later dysphonia and progressive dyspnea appeared. Lung CT scan showed the picture of organizing pneumonia. His COVID-19 PCR test was negative multiple times. Laboratory tests revealed the following numbers: ALT 210 IU/L, AST 748 IU/L, LDH 613 IU/L, CPK 1165 IU/L, ferritin 1145ϻg/l, CRB 11 mg/l. The patient was tested positive for anti-Ro52 antibodies, while anti-synthetase and scleroderma-associated antibodies were not discovered. Anti-melanoma differentiation-associated gene 5 (MDA5) test was not available due to the lack of the necessary test systems in the country. The patient was diagnosed with DM. Combined immunosuppressive therapy was administered, including: oral prednisolone 60 mg per day and 720 mg intravenously, dexamethasone 64-24 mg intravenously per diem, ciclosporin 200 mg и cyclophosphamide 600 mg, and 3 plasmapheresis sessions followed by an intravenous immunoglobulin. As a result of the therapy, muscle weakness disappeared and CPK levels returned to normal limits, however dyspnea progressed and ferritin levels hit 3500ϻg/l. After the following 3 weeks of intensive combined immunosuppressive therapy, the patient demonstrated symptoms of severe respiratory failure (RF). CT scan showed multiple traction bronchiectasis, wide areas of ground glass opacity, pneumomediastinum and subcutaneous emphysema of a neck and supraclavicular regions. Ciclosporin was replaced with tofacitinib with the dose of 10 mg per diem, IL-6 inhibitor (olokizumab 256 mg) was injected intravenously, massive broad-spectrum antibiotic therapy was administered. RF progressed and the patient was put on mechanical ventilation. The patient died of acute RF and sepsis a week later. DISCUSSION: RP-ILD is a common manifestation of severe MDA5+ DM, which is also associated with necrotizing vasculitis and amyopathic/hypomyopathic muscle involvement. In this case acute ILD in a patient with typical DM could also have been provoked by previous COVID-19 infection. CONCLUSIONS: The courses of disease for COVID-19 and MDA5+ DM have several similarities, which means it can be the same for their pathogenesis and clinical manifestations. In spite of early screening and intensive immunosuppressive therapy in such cases, the prognosis of patients with DM and RP-ILD is still poor and is associated with high mortality. Reference #1: Wang G, Wang Q, Wang Y, et al. Presence of Anti-MDA5 Antibody and Its Value for the Clinical Assessment in Patients With COVID-19: A Retrospective Cohort Study. Front Immunol. 2021 Dec 20;12:791348. doi: 10.3389/fimmu.2021.791348. PMID: 34987516;PMCID: PMC8720853. DISCLOSURES: No relevant relationships by Lidia Ananyeva No relevant relationships by Maria Aristova No relevant relationships by Liudmila Garzanova No relevant relationships by Anna Khelkovskaya-Sergeeva No relevant relationships by Dmitry Kulikovsky

13.
Chest ; 162(4):A1961-A1962, 2022.
Article in English | EMBASE | ID: covidwho-2060881

ABSTRACT

SESSION TITLE: Obstructive Lung Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Individual cases of pneumothorax, pneumomediastinum and subcutaneous emphysema have been reported in asthma attacks, but rarely coincide. Pathophysiology is secondary to obstruction in the minor airways leading to air-trapping and barotrauma of distal airways with subsequent alveolar rupture. This case illustrates a case of asthma exacerbation with a synchronous triad of rare complications. CASE PRESENTATION: 65-year-old female with a history of breast cancer, asthma and hypertension presented with shortness of breath, wheezing, and productive cough since four days ago. Vital signs were remarkable for tachypnea and saturation of 91%. Physical examination revealed respiratory distress, and auscultation disclosed diffuse inspiratory and expiratory wheezing. Limited bedside ultrasound showed B-lines compatible for pulmonary edema. Arterial blood gases were compatible with respiratory acidosis and hypoxemia. Laboratories showed leukocytosis, hypotonic hyponatremia, normal brain natriuretic peptide, and negative COVID-19 PCR test. Chest Xray (CXR) demonstrated changes concerning for pneumonia with superimposed pleural effusion. The patient was admitted with the impression of asthma exacerbation versus community acquired pneumonia. Initially, the patient was placed in bi-level positive airway pressure to aid in respiratory discomfort, broad spectrum antibiotic regimen, and diuresis therapy. On follow up, she was found hypoxic with periorbital edema, dyspnea, and subcutaneous emphysema in neck, upper extremities, and thorax for which emergent intubation was performed. CXR and Thoracic CT confirmed pneumomediastinum, large right sided pneumothorax and a moderate left sided pneumothorax requiring tube thoracostomy. At the Intensive Care Unit, treatment included combination therapies with levalbuterol, ipratropium, terbutaline, theophylline, budesonide, IV steroids and magnesium without appropriate response. Mechanical ventilator was set to protective lung parameters to avoid worsening barotrauma. Subsequently, she was paralyzed for 48 hours to aid in synchrony and allow adequate pulmonary gas exchange. Nonetheless, severe bronchoconstriction was persistent along with depressed neurological status. Two months later, the patient passed away. DISCUSSION: We believe our patient developed barotrauma secondary to a cough attack combined with positive airway pressure. Similarities in presentation such as dyspnea, tachycardia, and hypoxia may prove difficult in differentiation. Although each of these pathologies separately can generally be self-limiting depending on size and hemodynamic compromise, the combination can be mortal and clinical suspicion is important in fast diagnosis and treatment. CONCLUSIONS: Our case demonstrates the importance of suspicion of barotrauma in patients with asthma attacks not responding adequately to therapy or developing worsening hypoxia which can be detrimental. Reference #1: Franco, A. I., Arponen, S., Hermoso, F., & García, M. J. (2019). Subcutaneous emphysema, pneumothorax and pneumomediastinum as a complication of an asthma attack. The Indian journal of radiology & imaging, 29(1), 77–80. https://doi.org/10.4103/ijri.IJRI_340_18 Reference #2: Zeynep Karakaya, Şerafettin Demir, Sönmez Serkan Sagay, Olcay Karakaya, Serife Özdinç, "Bilateral Spontaneous Pneumothorax, Pneumomediastinum, and Subcutaneous Emphysema: Rare and Fatal Complications of Asthma", Case Reports in Emergency Medicine, vol. 2012, Article ID 242579, 3 pages, 2012.https://doi.org/10.1155/2012/242579 Reference #3: Subcutaneous Emphysema in Acute Asthma: A Cause for Concern? Patrick D Mitchell, Thomas J King, Donal B O'Shea Respiratory Care Aug 2015, 60 (8) e141-e143;DOI: 10.4187/respcare.03750 DISCLOSURES: No relevant relationships by Juan Adams-Chahin No relevant relationships by Gretchen Marrero No relevant relationships by natalia Mestres No relevant relationships by Are is Morales Malavé No relevant relationships by Carlos Sifre No relevant relationships by Paloma Velasco No relevant relationships by Mark Vergara-Gomez

14.
Chest ; 162(4):A1814, 2022.
Article in English | EMBASE | ID: covidwho-2060869

ABSTRACT

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema are reported as rare complications of COVID-19 pneumonia in various observational studies. The purpose of this study is to investigate the incidence of these complications and their outcome in hospitalized patients with COVID-19 pneumonia, at our inner-city hospital system in Central Pennsylvania. METHODS: We performed a retrospective chart review of the patients admitted with COVID-19 pneumonia from March 2020 to March 2021 in 3 different hospitals located in central Pennsylvania. Data on their demographics, pre-existing comorbidities, inpatient location, radiologic findings, timeline of events, mode of oxygenation and ventilation, hematology, chemistry profile and inflammatory markers were obtained. Patients with known inciting events for barotrauma, other than COVID-19 pneumonia were excluded from our analysis. RESULTS: The mean age of patient cohort was 66 years (SD 14.07). Almost fifty two percent were obese with BMI more than 30 kg/m2 and 69.5% were male. Only 11.4% of the study population had history of COPD and majority (63.6%) did not have history of smoking. Out of 31,260 inpatients, only 44 (0.0014 %) patients spontaneously developed thoracic free air. Among them, 33 (75%) had pneumothorax, and 22 (50%) needed chest tube for the management. 18 (40.9%) had pneumomediastinum, and 20 (45.5%) had subcutaneous emphysema. These are not exclusive findings and some patients had free air in more than one location. Thirty (68.2%) patients were admitted to ICU (Intensive Care Unit), 20 (45.5%) patients needed invasive ventilation and 26 (61.4%) had in-hospital mortality. Mortality in ICU was significantly high (86.67%) compared to non-ICU patients (7.14%). The average duration of hospitalization was 28.18 days (SD 25.46). CONCLUSIONS: Incidence of spontaneous thoracic free air complication in COVID –19 pneumonia is a rare phenomenon. In our patient cohort, occurrence of these events was seen irrespective of type of oxygen delivery and ventilation. However, patients having these complications had a high rate of ICU admission. Mortality is significantly high especially in patients admitted to ICU. CLINICAL IMPLICATIONS: Spontaneous thoracic free air complication in COVID-19 pneumonia is rare but can be a marker of poor prognosis. Vaccination status of study population was unknown, therefore the role of vaccination to prevent these complications and their outcome needs to be explored. DISCLOSURES: No relevant relationships by Yi-Ju Chen No relevant relationships by Anatoliy Korzhuk No relevant relationships by Rajan Pathak No relevant relationships by Navitha Ramesh No relevant relationships by Michaela Sangillo

15.
Chest ; 162(4):A1572, 2022.
Article in English | EMBASE | ID: covidwho-2060842

ABSTRACT

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pulmonary clinicians are all too familiar with the ground-glass and consolidative pulmonary opacities that are the hallmark of COVID-19 pneumonia on imaging. As the pandemic continues, we encounter an ever-growing list of complications of SARS-CoV-2 infection. Pneumatoceles are thin-walled, gas-filled spaces within the lungs that occur in association with pneumonia or chest trauma and typically resolve spontaneously1 but may rupture and cause pneumothorax2. Reports of pneumatoceles due to COVID-19 are uncommon. In this case report, I describe a patient who developed large bilateral pneumatoceles as a complication of COVID-19. CASE PRESENTATION: A 25-year-old male non-smoker with no significant past medical history presented with dyspnea after a lab-confirmed diagnosis of COVID-19 nine days prior. Initial chest radiograph showed multifocal bilateral airspace infiltrates consistent with COVID-19 pneumonia. He was admitted for management of acute hypoxic respiratory failure and treated with dexamethasone, remdesivir, and tocilizumab. He required heated high-flow nasal cannula oxygen up to 60 LPM but did not require CPAP or mechanical ventilation. On hospital day 5 he developed increasing tachypnea and exertional desaturation. CT pulmonary angiogram (CTPA) ruled-out pulmonary embolus but revealed progression of bilateral infiltrates and extensive pneumomediastinum with subcutaneous air in the neck and chest wall, and no clear evidence for pneumothorax. The patient discharged on day 12 with oxygen but returned 2 days later with new onset hemoptysis. CTPA on admission showed new bilateral pneumothoraces and he was transferred to a quaternary hospital for intensive care where bilateral chest tubes were placed. Repeat CT Chest after lung expansion revealed bilateral cystic areas within the lungs initially concerning for necrotizing infection. Bacterial and fungal cultures were negative. Despite resolution of the pneumothoraces and removal of chest tubes, he continued to experience hemoptysis and chest pain. CT Chest demonstrated enlargement of now clearly very large pneumatoceles with air-fluid levels. After conservative management and discharge, a 6-week surveillance CT showed significant decrease in the pneumatoceles but a new moderate-to-large right pneumothorax. Ultimately after 2 more admissions and 90 days since COVID-19 diagnosis, he underwent wedge resection and mechanical pleurodesis for definitive management of secondary pneumothoraces. DISCUSSION: A pneumatocele, especially when large and containing an air-fluid level, may mimic hydropneumothorax, empyema, or pulmonary abscess among other diagnoses. Failure to recognize a pneumatocele and differentiate it from other conditions could lead to inappropriate treatment and cause patient harm3. CONCLUSIONS: It is important to recognize pneumatoceles as a potential complication in the post COVID-19 setting to guide appropriate management. Reference #1: Quigley, M. J., & Fraser, R. S. (1988). Pulmonary pneumatocele: pathology and pathogenesis. AJR. American journal of roentgenology, 150(6), 1275–1277. https://doi.org/10.2214/ajr.150.6.1275 Reference #2: Odackal, J., Milinic, T., Amass, T., Chan, E. D., Hua, J., & Krefft, S. (2021). A 28-Year-Old Man With Chest Pain, Shortness of Breath, and Hemoptysis After Recovery From Coronavirus Disease 2019 Pneumonia. Chest, 159(1), e35–e38. https://doi.org/10.1016/j.chest.2020.07.096 Reference #3: Jamil A, Kasi A. Pneumatocele. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556146/ DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: 2018 to present Added 04/01/2022 by Erin Peterson, value=Honoraria

16.
Chest ; 162(4):A1383-A1384, 2022.
Article in English | EMBASE | ID: covidwho-2060812

ABSTRACT

SESSION TITLE: COVID-19 Infections: Issues During and After Hospitalization SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Pneumothorax and pneumomediastinum (PTX/PM) has been associated with patients hospitalized with COVID-19 infections. The aim of our study was to assess the risk factors, hospital length of stay, and mortality of PTX/PM among hospitalized patients with COVID-19 infection in a matched case-controlled study. METHODS: Adult patients with confirmed COVID-19 infections who were hospitalized at 5 Mayo Clinic hospitals (Minnesota, Arizona, Florida, Wisconsin) between March 2020 and January 2022 were retrospectively screened. PTX and or PM in at least two consecutive imaging studies were included. They were matched to control patients based on age, gender, hospital admission period, severity on admission day and the day preceding the incident. Summary statistics, Mann Whitney-U, and chi-square tests were performed RESULTS: A total of 197 patients were included in the descriptive analyses.The median age was 61 years and the majority were men (70.8%). Patients with underlying pulmonary comorbidities was 2.27 (OR 1.42-3.62, p value < 0.001) times more likely to develop PTX/PM. Ten percent of the total cases had these complications present upon hospital admission.Patients who developed PTX/PM had a longer hospital length of stay compared to controls, 20 versus 12 days, OR 4.53 (p=0.002). On the day prior to developing PTX/PM, 42 (31%) of patients had been on high-flow nasal cannula only and 14 on non-invasive ventilation (10.4%). The highest recorded positive end-expiratory pressure, plateau, and driving pressures were recorded in our case group on the day before the complication and all were significantly higher than matched controls. In-hospital mortality in patients whose COVID-19 course was complicated by PTX/PM was 44.2% vs. those without, 21.1%, adjusted OR 2.71 (p=0.001). Sixty two percent were treated conservatively without any intervention. CONCLUSIONS: We have demonstrated in the largest study to date, that patients who were hospitalized with COVID-19 infection and had a PTX/PM had a longer hospital length of stay, were associated with higher mechanical ventilatory pressures, and had a higher in-hospital mortality, when compared with matched controls. CLINICAL IMPLICATIONS: Complications of PTX/PM in patients with COVID-19 infections can occur spontaneously and in barotrauma. Pre-existing lung disease is a risk factor for the development of these complications. Patients with PTX/PM have a longer hospital length of stay and higher in-hospital mortality which is in contrast with existing published data. DISCLOSURES: No relevant relationships by Natalya Azadeh No relevant relationships by Meghan Brown No relevant relationships by Rodrigo Cartin-Ceba No relevant relationships by Anusha Devarajan No relevant relationships by Juan Pablo Domecq No relevant relationships by Sandeep Khosa No relevant relationships by Amos Lal No relevant relationships by Shahraz Qamar No relevant relationships by Kenneth Sakata No relevant relationships by Mayank Sharma No relevant relationships by Nikhil Sharma No relevant relationships by Jamil Taji No relevant relationships by Fahimeh Talaei No relevant relationships by Aysun Tekin No relevant relationships by Diana Valencia Morales No relevant relationships by Stephanie Welle

17.
Chest ; 162(4):A1365, 2022.
Article in English | EMBASE | ID: covidwho-2060810

ABSTRACT

SESSION TITLE: Bad bugs and Mediastinal Madness SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Non-traumatic bronchial injury (NTBI) incidence is not well described but traumatic Tracheobronchial injury (TBI) incidence is 3% with a 70 -100% mortality3. Causes identified for NTBI are associated with vascular supply compromise2. TBI presents with dyspnea, subcutaneous emphysema, pneumothorax, and/or pneumomediastinum4. It can be missed up to 68% of the cases. Bronchoscopy is the study of choice and management is based on studies from traumatic TBI2, 3. This report describes a unique case of NTBI in a patient with recent COVID-19 infection, uncontrolled diabetes, and invasive pseudomembranous Aspergillosis presenting with a left bronchial tear (LBT). CASE PRESENTATION: A 41-year-old with uncontrolled diabetes and prior admission for COVID-19 infection and diabetic ketoacidosis (DKA) managed with steroids and antibiotics. Presenting cough, fever, intermittent chest pain, and palpitations. He was afebrile, tachycardic, and hypoxemic requiring supplemental oxygen. Chest examination revealed crackles and decreased breath sounds at the lung bases. Laboratory studies showed leukocytosis, hyperglycemia, and anion gap metabolic acidosis. SARS-CoV-2 PCR was negative. CT chest revealed an anterior wall defect of the left bronchus with a pneumomediastinum. Bronchoscopy showed pseudomembranous necrotic debris of the tracheobronchial tree and left main bronchus tear with visible rhythm-beating pericardium surrounding the heart. Cytopathological findings of the bronchoalveolar fluid were consistent with Aspergillus species (AS). DISCUSSION: NTBI are rare with a high mortality3. NTBI due to AS has been described in post-lung transplant patients. AS produces endotoxins and proteases that damage the epithelium, leading to erosion of surrounding structures2,3. Since COVID-19, invasive fungal infections (IFI) have risen due to lung damage and immunologic deficits associated with the virus or immunomodulatory therapy6. Our patient risk factors for IFI included recent COVID-19 infection, steroid use, and uncontrolled diabetes. This unholy trinity has coexisted during COVID-19 self-potentiating the problem of immune dysregulation leading to IFI and tissue necrosis7. This may cause NTBI as in our case presenting with LBT. Despite antimicrobial therapy, he died due to massive hemoptysis from erosion of the pericardium or angio-invasion of surrounding vessels. CONCLUSIONS: Rarity of NTBI constitutes a challenge for early diagnosis and management. Identifying predisposing risk factors, a high clinical suspicion, and appropriate diagnostic workup is of vital importance. During the COVID-19 pandemic, IFI have an increased incidence associated with high mortality rates. Despite more cases being described there are still knowledge gaps related to prevention, diagnosis, and management. Reference #1: Jones D, Nelson A, Ma OJ. Pulmonary Trauma. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw-Hill Education;2016. accessmedicine.mhmedical.com/content.aspx?aid=1121516674 Reference #2: Aerni MR, Parambil JG, Allen MS, Utz JP. Nontraumatic Disruption of the Fibrocartilaginous Trachea: Causes and Clinical Outcomes. Chest. 2006;130(4):1143-1149. doi:https://doi.org/10.1016/S0012-3692(15)51151-3 Reference #3: AK AK, Anjum F. Tracheobronchial Tear. StatPearls Publishing;2022. Accessed March 13, 2022. https://www.ncbi.nlm.nih.gov/books/NBK560900/ DISCLOSURES: No relevant relationships by Jorge Alejandro Bernal No relevant relationships by Adriana Betancourth No relevant relationships by Reham Majzoub No relevant relationships by Juan Pablo Sarmiento Cano

18.
Chest ; 162(4):A1360-A1361, 2022.
Article in English | EMBASE | ID: covidwho-2060809

ABSTRACT

SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: High Flow Nasal Cannula (HFNC) is a non-invasive ventilation (NIV) device widely used to manage hypoxemic respiratory failure. Data about optimal flow rate and time length for safety is lacking. Cases of spontaneous pneumomediastinum (SP) during HFNC oxygen therapy in COVID-19 patients have been recently reported. A study in airway models suggests a non-linear increase in PEEP up to 10 cmH2O in adults on maximum tested flows. Prolonged use of NIV could also delay escalation to invasive ventilation and use of lung-protective volumes (LPV). The ROX-index is a predictive tool for NIV failure and continuous evaluation of intubation indications. This study aimed to identify risk factors associated with the development of SP in COVID-19 ARDS on HFNC support and establish mitigating behavior that will aid in safer COVID-19 treatment modalities. METHODS: Cases from 2020 to 2022 were reviewed. Patients with SP while on HFNC were included as cases. Age and gender-matched patients who received HFNC and did not develop SP were controls. Baseline characteristics between groups were compared using t-test for continuous variables and chi-square for categorical values. Longitudinal ROX scores were calculated until the last day (day of pneumomediastinum development for SP group, and death or MV commencement for controls). Nominal logistic regression was performed to identify variables associated with SP development. Parameter Estimates were used to construct a prediction model, and a ROC curve was implemented to assess the accuracy of the prediction of SP events. RESULTS: Total 61 patients enrolled, 52% (32/61) developed SP on HFNC and 48% (29/61) were control group (CG). No statistical significance found on baseline demographics. Median HFNC days-to-SP was 7 [standard deviation (SD), 6.8 days]. Median days from COVID-19 diagnosis-to-SP was 9 (SD, 5 days). Use of MV was greater in SP group (29 vs 3, p-value < 0.001) and use of vassopresor support (28 vs 3, p-value < 0.001). SP-group had an increased mortality compared to CG, with 88% (28/32) vs.12% (3) (p-value, <0.001). Median ROX scores on Day 1 were 5.45 for SP group and 18.2 for CG (p<0.001). Median ROX scores on last day (day-to-event) were 4.08 and 9.4 in CG (p<0.001). Nominal logistic regression identified number of days on HFNC, ROX score on day 1, and cumulative amount of Flow rate, as independent variables associated with SP development. ROC of the Prediction model using parameter estimates from these 3 variables had an AUC of 0.922. CONCLUSIONS: Development of SP is associated with increased mortality. Patients with lower ROX scores at initiation of therapy, prolonged days of HFNC and increased cumulative flow rates are associated with the development of SP. CLINICAL IMPLICATIONS: HFNC has the potential to cause alveolar damage, however a larger patient population size is needed to further analyze the relationship of HFNC use and the development of SP. DISCLOSURES: No relevant relationships by Sofia Durscki Vianna No relevant relationships by Cynthia Espinosa No relevant relationships by Hernando Garcia No relevant relationships by Ephraim Mansour No relevant relationships by Laura Mendez Morente No relevant relationships by Zuleikha Muzaffarr No relevant relationships by Sergio Poli No relevant relationships by Luisa Quesada No relevant relationships by Douglas Salguero No relevant relationships by Michelle Yousefzadeh

19.
Chest ; 162(4):A1327-A1328, 2022.
Article in English | EMBASE | ID: covidwho-2060807

ABSTRACT

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

20.
Chest ; 162(4):A1061-A1062, 2022.
Article in English | EMBASE | ID: covidwho-2060763

ABSTRACT

SESSION TITLE: Lessons Learned from Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Air outside the lungs, bowel, or paranasal cavities suggests critical pathology. Pneumoperitoneum is a classic example in which free abdominal air may signify hollow viscus injury and the need for emergent surgical management. Ectopic gas can also be secondary to barotrauma secondary to mechanical ventilation and concurrent lung injury;the latter being findings often observed in COVID pneumonia (1,2,3). Our case of extensive intramedullary gas in the setting of COVID pneumonia is an example of extensive dissecting air related to barotrauma, but also illustrates how it mimics dire cases of pneumoperitoneum. Therefore, it is an imaging finding that intensivists caring for COVID pneumonia patients should be aware of. CASE PRESENTATION: A 52-year-old male with mild restrictive lung disease from congenital scoliosis developed COVID pneumonia and hypoxic respiratory failure requiring intubation. Clinical course was complicated by renal failure, deep venous thromboses, and radial artery occlusion. CT evaluation revealed large volume upper abdominal pre-peritoneal gas, pneumoperitoneum, soft tissue and intramedullary gas within bilateral ribs and multiple vertebral bodies. Despite reassuring abdominal exams, the patient deteriorated. The patient was placed on comfort care and expired. DISCUSSION: Intramedullary gas refers to the presence of air within the cortical or trabecular bone, bone marrow, or medullary cavity. It is an exceedingly rare imaging finding which was first described in ischemic vertebral collapse and osteomyelitis (4,5). Differential diagnosis includes infection, trauma, degenerative and iatrogenic causes (5,6). Embryologically, fascial layers of the thorax and periosteal coverings of the thoracic osseous structures are derived from the mesoderm, thus creating a continuum between the lungs, surrounding soft tissues, peritoneum, and surrounding osseous structures, and therefore allowing gas to travel between the lung and intramedullary space (7). As cases of COVID pneumonia with ARDS increase, we are becoming aware of the increasing incidence of ectopic air, and the poor prognosis and increased mortality that results (1). Therefore, the finding of intramedullary gas is an important prognostic indicator that the clinician should be aware of. CONCLUSIONS: Several recent studies demonstrate increased mortality in COVID patients who develop ectopic gas as a result of barotrauma and/or acute lung injury (1,2,3). As such the clinician should be aware of these findings, which include pneumomediastinum, subcutaneous emphysema, pneumoperitoneum, pre-peritoneal air, and intramedullary gas for early recognition. Reference #1: 1. Lemmers DHL, Abu Hilal M, Bnà C, Prezioso C, Cavallo E, Nencini N, Crisci S, Fusina F, Natalini G. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty? ERJ Open Res. 2020 Nov 16;6(4):00385-2020. doi: 10.1183/23120541.00385-2020. PMID: 33257914;PMCID: PMC7537408. Reference #2: 2. Guven BB, Erturk T, Kompe Ö, Ersoy A. Serious complications in COVID-19 ARDS cases: pneumothorax, pneumomediastinum, subcutaneous emphysema and haemothorax. Epidemiol Infect. 2021 Jun 8;149:e137. doi: 10.1017/S0950268821001291. PMID: 34099076;PMCID: PMC8207553. Reference #3: 3. Tetaj N, Garotto G, Albarello F, Mastrobattista A, Maritti M, Stazi GV, Marini MC, Caravella I, Macchione M, De Angelis G, Busso D, Di Lorenzo R, Scarcia S, Farina A, Centanni D, Vargas J, Savino M, Carucci A, Antinori A, Palmieri F, D'Offizi G, Ianniello S, Taglietti F, Campioni P, Vaia F, Nicastri E, Girardi E, Marchioni L, Icu Covid-Study Group. Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate-Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital. J Clin Med. 2021 Nov 29;10(23):5608. doi: 10.3390/jcm10235608. PMID: 34884310;PMCID: PMC8658701. DISCLOSURES: Researc support relationship with 4D Medical Please note: March 2021 Added 04/04/2022 by Anu Brixey, value=Grant/Research Support No relevant relationships by raluca mccallum

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