Chest Tightness with Cycling Turned Out To Be Pneumomediastinum.

BACKGROUND Pneumomediastinum, or mediastinal emphysema, means air present inside the mediastinum. It usually presents with symptoms of chest pain and shortness of breath. Examination can be significant for crepitus along the neck area. There are many risk factors associated with pneumomediastinum, including asthma and COVID-19. Most cases of pneumomediastinum improve with conservative management, and surgery (mediastinotomy) is reserved for complicated cases with tension pneumomediastinum. CASE REPORT This is the case of a 23-year-old man who presented with chest tightness after 3.5 h of cycling. The patient did have a prior history of clinically stable asthma, with no recent exacerbation, and denied any other associative factors. Imaging was significant for pneumomediastinum. The patient was admitted for observation in the hospital and treated with supportive care, without any surgical intervention. The patient had appropriate improvement in his symptoms in 24 h. Repeat imaging showed improvement in the pneumomediastinum, and the patient was discharged to outpatient follow-up. CONCLUSIONS Our case presents a unique link between cycling and pneumomediastinum. Prolonged cycling may emerge as a risk factor for this complication. People with a previous history of pneumomediastinum should be careful to review other risk factors prior to planning long-distance bicycling. Physicians need to keep this differential diagnosis in mind when encountering a patient with similar symptoms so that a timely diagnosis is made.

The Macklin effect closely correlates with pneumomediastinum in acutely ill intubated patients with COVID-19 infection.

PURPOSE: Patients with COVID-19 infection are frequently found to have pulmonary barotrauma. Recent work has identified the Macklin effect as a radiographic sign that often occurs in patients with COVID-19 and may correlate with barotrauma. METHODS: We evaluated chest CT scans in COVID-19 positive mechanically ventilated patients for the Macklin effect and any type of pulmonary barotrauma. Patient charts were reviewed to identify demographic and clinical characteristics. RESULTS: The Macklin effect on chest CT scan was identified in a total of 10/75 (13.3%) COVID-19 positive mechanically ventilated patients; 9 developed barotrauma. Patients with the Macklin effect on chest CT scan had a 90% rate of pneumomediastinum (p < 0.001) and a trend toward a higher rate of pneumothorax (60%, p = 0.09). Pneumothorax was most frequently omolateral to the site of the Macklin effect (83.3%). CONCLUSION: The Macklin effect may be a strong radiographic biomarker for pulmonary barotrauma, most strongly correlating with pneumomediastinum. Studies in ARDS patients without COVID-19 are needed to validate this sign in a broader population. If validated in a broad population, future critical care treatment algorithms may include the Macklin sign for clinical decision making and prognostication.

Surgical management of pneumomediastinum in the COVID-19 patient.

As the SARS-CoV-2 virus continues to infect millions of people worldwide, the medical profession is seeing a wide range of short-term and long-term complications of COVID-19. One lesser-known complication is that of pneumomediastinum. This is a rare, but significant, complication defined by the presence of air in the mediastinum with an incidence of 1.2 per 100 000. Described mortality rate is 30%, increasing to 60% in patients with concomitant pneumothoraces. Management of pneumomediastinum is typically conservative, but in cases of extensive subcutaneous emphysema, cardiac or airway compression, life-saving surgical decompression is necessary. We report a case of pneumomediastinum secondary to COVID-19, requiring a surgical approach not described in pneumomediastinum secondary to COVID-19. The case demonstrates the importance of prompt diagnosis and management, as well as the potential for good clinical outcome in selected patients.

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.

Pneumomediastinum: a rare complication in COVID-19 patients.

A 62-year-old man with COVID-19 had PS for fever, coughing, and breathlessness. Two days after therapy, the patient's clinical condition worsened. X-ray and CT showed pneumomediastinum, emphysema and pneumothorax. The patient was intubated and subjected to conservative therapy. The patient was discharged after about 20 days. Radiological imaging plays a key role in the proper diagnosis and treatment of COVID-19 patients with related complications.

Mechanical Ventilation Associated Pneumomediastinum - A Rising Incidence of Cases in an Emergency Hospital During the COVID-19 Pandemics.

Introduction: Mechanical ventilation is a last resort solution for patients presenting with acute respiratory distress syndrome produced by SARS-CoV-2. Spontaneous pneumomediastinum is a rare pathology associated with invasive mechanical ventilation. The objective of our research was to highlight the increased incidence of spontaneous pneumomediastinum during the COVID-19 pandemics in our hospital. Material and method: A retrospective review of the cases in our hospital requiring surgical evaluation was performed. Electronic health records from our institution were searched for nontraumatic pneumomediastinum from October to November 2021. All patients that were identified with pneumomediastinum were included in the review. Results: We identified 12 mechanical ventilated patients that presented with free air in the mediastinum on a computed tomography during the study period. All of the patients had SARS-CoV-2 bronchopneumonia with extensive pulmonary involvement. The mortality rate among these patients was 58.33%. Conclusions: The main take-home message of our study is that the incidence of mechanically ventilation-associated pneumomediastinum was exponentially higher during the fourth wave of COVID-19. There is a need for multicenter data in this pathology for a better approach and to define surgical management options for these patients.

Barotrauma in COVID 19: Incidence, pathophysiology, and effect on prognosis.

OBJECTIVES: To investigate the incidence, risk factors, and outcomes of barotrauma (pneumomediastinum and subcutaneous emphysema) in mechanically ventilated COVID-19 patients. To describe the chest radiography patterns of barotrauma and understand the development in relation to mechanical ventilation and patient mortality. METHODS: We performed a retrospective study of 363 patients with COVID-19 from March 1 to April 8, 2020. Primary outcomes were pneumomediastinum or subcutaneous emphysema with or without pneumothorax, pneumoperitoneum, or pneumoretroperitoneum. The secondary outcomes were length of intubation and death. In patients with pneumomediastinum and/or subcutaneous emphysema, we conducted an imaging review to determine the timeline of barotrauma development. RESULTS: Forty three out of 363 (12%) patients developed barotrauma radiographically. The median time to development of either pneumomediastinum or subcutaneous emphysema was 2 days (IQR 1.0-4.5) after intubation and the median time to pneumothorax was 7 days (IQR 2.0-10.0). The overall incidence of pneumothorax was 28/363 (8%) with an incidence of 17/43 (40%) in the barotrauma cohort and 11/320 (3%) in those without barotrauma (p ≤ 0.001). In total, 257/363 (71%) patients died with an increase in mortality in those with barotrauma 33/43 (77%) vs. 224/320 (70%). When adjusting for covariates, barotrauma was associated with increased odds of death (OR 2.99, 95% CI 1.25-7.17). CONCLUSION: Barotrauma is a frequent complication of mechanically ventilated COVID-19 patients. In comparison to intubated COVID-19 patients without barotrauma, there is a higher rate of pneumothorax and an increased risk of death.

Case Of Pneumomediastinum And Surgical Emphysema In A Patient With Covid-19 Pneumonia, On Cpap.

An unusual case of a 35-year-old woman with COVID-19 pneumonia who suddenly desaturated while on continuous positive airway pressure leading to pneumomediastinum and surgical emphysema thereby requiring ventilatory support in intensive therapy unit. It is unclear from history and clinical assessment; whether this complication was directly related to COVID-19 pneumonia and it worsened with the initiation of CPAP, OR it was a direct complication of CPAP.

Macklin effect on baseline chest CT scan accurately predicts barotrauma in COVID-19 patients.

PURPOSE: To validate the role of Macklin effect on chest CT imaging in predicting subsequent occurrence of pneumomediastinum/pneumothorax (PMD/PNX) in COVID-19 patients. MATERIALS AND METHODS: This is an observational, case-control study. Consecutive COVID-19 patients who underwent chest CT scan at hospital admission during the study time period (October 1st, 2020-April 31st, 2021) were identified. Macklin effect accuracy for prediction of spontaneous barotrauma was measured in terms of sensitivity, specificity, positive (PPV) and negative predictive values (NPV). RESULTS: Overall, 981 COVID-19 patients underwent chest CT scan at hospital arrival during the study time period; 698 patients had radiological signs of interstitial pneumonia and were considered for further evaluation. Among these, Macklin effect was found in 33 (4.7%), including all 32 patients who suffered from barotrauma lately during hospital stay (true positive rate: 96.9%); only 1/33 with Macklin effect did not develop barotrauma (false positive rate: 3.1%). No barotrauma event was recorded in patients without Macklin effect on baseline chest CT scan. Macklin effect yielded a sensitivity of 100% (95% CI: 89.1-100), a specificity of 99.85% (95% CI: 99.2-100), a PPV of 96.7% (95% CI: 80.8-99.5), a NPV of 100% and an accuracy of 99.8% (95% CI: 99.2-100) in predicting PMD/PNX, with a mean advance of 3.2 ± 2.5 days. Moreover, all Macklin-positive patients developed ARDS requiring ICU admission and, in 90.1% of cases, invasive mechanical ventilation. CONCLUSIONS: Macklin effect has high accuracy in predicting PMD/PNX in COVID-19 patients; it is also an excellent predictor of disease severity.

Pneumomediastinum in patients with COVID-19 undergoing CT pulmonary angiography: a retrospective cohort study.

BACKGROUND: Various complications have been reported in patients with COVID-19 including pneumomediastinum. METHODS: The primary objective of the study was to determine the incidence of pneumomediastinum in COVID-19 positive patients who underwent CT pulmonary angiography (CTPA). The secondary objectives were to analyse if the incidence of pneumomediastinum changed between March and May 2020 (peak of the first wave in the UK) and January 2021 (peak of the second wave in the UK) and to determine the mortality rate in patients with pneumomediastinum. We undertook an observational, retrospective, single-centre, cohort study of patients with COVID-19 admitted to Northwick Park Hospital. RESULTS: 74 patients in the first wave and 220 patients in the second wave met the study criteria. Two patients during the first wave and eleven patients during the second wave developed pneumomediastinum. CONCLUSIONS: The incidence of pneumomediastinum changed from 2.7% during the first wave to 5% during the second wave and this change was not statistically significant (p value 0.4057). The difference in mortality rates of patients with pneumomediastinum in both waves of COVID-19 (69.23%) versus patients without pneumomediastinum in both waves of COVID-19 (25.62%) was statistically significant (p value 0.0005). Many patients with pneumomediastinum were ventilated, which could be a confounding factor. When controlling for ventilation, there was no statistically significant difference in the mortality rates of ventilated patients with pneumomediastinum (81.81%) versus ventilated patients without pneumomediastinum (59.30%) (p value 0.14).

Incidence and Clinical Features of Pneumomediastinum and Pneumothorax in COVID-19 Pneumonia.

BACKGROUND: Pneumothorax (PTX) and pneumomediastinum (PM), collectively termed here "air leak", are now well described complications of severe COVID-19 pneumonia across several case series. The incidence is thought to be approximately 1% but is not definitively known. OBJECTIVES: To report the incidence and describe the demographic features, risk factors and outcomes of patients with air leak as a complication of COVID-19. METHODS: A retrospective observational study on all adult patients with COVID-19 admitted to Watford General Hospital, West Hertfordshire NHS Trust between March 1st 2020 and Feb 28th 2021. Patients with air leak were identified after reviewing both chest radiographs (CXRs) and axial imaging (CT Thorax) with confirmatory radiology reports inclusive of the terms PTX and/or PM. RESULTS: Air leak occurred with an incidence of 0.56%. Patients with air leak were younger and had evidence of more severe disease at presentation, including a higher median CRP and number of abnormal zones affected on chest radiograph. Asthma was a significant risk factor in the development of air leak (OR 13.4 [4.7-36.4]), both spontaneously and following positive pressure ventilation. CPAP and IMV were also associated with a greater than six fold increase in the risk of air leak (OR 6.4 [2.5-16.6] and 9.8 [3.7-27.8] respectively). PTX, with or without PM, in the context of COVID-19 pneumonia was almost universally fatal whereas those with alone PM had a lower risk of death. CONCLUSION: Despite the global vaccination programme, patients continue to develop severe COVID-19 disease and may require respiratory support. This study demonstrates the importance of identifying that deterioration in such patients may be resultant from PTX or PM, particularly in asthmatics and those managed with positive pressure ventilation.