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.

Spontaneous Pneumomediastinum in COVID-19 Pneumonia: A Rare Occurence.

Spontaneous pneumomediastinum with COVID pneumonia is a rare occurrence with or without accompanying subcutaneous emphysema or pneumothorax. The aim of this study was to establish relation of this complication to severity of lung disease and its clinical outcome. The study was conducted for a period of seven months from April to October 2020 in the CT Department of Armed Forces Institute of Radiology and Imaging (AFIRI), Rawalpindi, Pakistan. All COVID positive patients having spontaneous pneumomediastinum on high resolution CT (HRCT) chest were included (n=14). These patients were assessed for severity of lung disease as per CT severity score (CTSS), and were followed up for their clinical outcome. All patients with spontaneous pneumomediastinum had moderate to severe degree of COVID pneumonia; mortality in patients with pneumomediastinum was 50%; and was seen in those patients who had greater severity of lung disease as per the CTSS. Key Words: Spontaneous, Pneumomediastinum, COVID, Pneumothorax, Subcutaneous, Emphysema.

Spontaneous Massive Pneumomediastinum in a Previously Well Infant With COVID-19.

A 3-month-old boy presented with a 3-hour history of a neck lump and difficulty breathing after 5 days of fever and reduced feeding. Pneumomediastinum with subcutaneous emphysema were identified, and the child was intubated because of severe work of breathing, requiring significant levels of oxygen and ventilatory pressure. Computed tomography chest scan revealed massive pneumomediastinum and significant bilateral parenchymal disease. The child deteriorated cardiovascularly, so the mediastinum was dissected by cardiothoracic surgeons and 2 drains were placed. The patient clinically improved with resolution of air leak over 2 days. A diagnosis of coronavirus disease 2019 pneumonia was confirmed.

[SARS-CoV-2-associated pneumothorax, pneumomediastinum and soft tissue emphysema. Clinical implications based on a case series]. / SARS-CoV-2-assoziierter Pneumothorax, Pneumomediastinum und Weichteilemphysem. Klinische Implikationen anhand einer Fallserie.

The new coronavirus (SARS-CoV-2) that arose in 2019 causes a wide spectrum of symptoms and different courses of disease. Pneumothorax, pneumomediastinum and soft tissue emphysema are rare complications in patients with pulmonary involvement. They are the sequelae of severe, virus-induced structural changes of the pulmonary architecture. High pressure artificial ventilation aggravates the problem. Hence pneumothorax and ectopic air in soft tissues are indicators of extensive pulmonary damage. Therefore, efforts should be made to treat even very small or multiply recurrent pneumothorax by drainage procedures.

Is Spontaneous Pneumomediastinum a Poor Prognostic Factor in Covid-19?

OBJECTIVE: To determine the risk factors for spontaneous pneumomediastinum (SPM), its clinical course and effect on prognosis in patients with Coronavirus disease-19 (COVID-19) pneumonia. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Kayseri City Training and Research Hospital, Turkey, from April  to September 2020. METHODOLOGY: All COVID-19 patients' clinical, laboratory, and radiologic characteristics, as well as treatment outcome data, were obtained through medical record extraction. Group A had 50 patients (22 men and 28 women) without SPM, and Group B had 20 patients (10 men and 10 women) with SPM. RESULTS: Considering the accompanying comorbidities, the frequencies of asthma and inhaler-use was significantly higher in Group B than in Group A (p <0.05). In the CT evaluation at presentation, the rate of involvement of all five lobes of the lung in Group B was significantly higher than in Group A. Rates of tube thoracostomy, mechanical ventilator requirement, length of stay in hospital, and exitus were significantly higher in Group B than in Group A (p <0.05). CONCLUSION: SPM development in a patient with COVID-19 pneumonia is a sign that the prognosis will not be good, and these patients need a more aggressive treatment. Key Words: Spontaneous pneumomediastinum, COVID-19, Pneumothorax, Real-time polymerase chain reaction, Subcutaneous emphysema.

Spontaneous pneumomediastinum and subcutaneous emphysema in a non-intubated COVID-19 patient: a case report.

The development of spontaneous pneumomediastinum and subcutaneous emphysema are few of the rare clinical manifestations observed in coronavirus disease-19 (COVID-19) patients which are yet to be fully understood. Most cases of spontaneous pneumomediastinum arise due to factors causing high intra-alveolar pressure. Herein, we report a case of a COVID-19 positive elderly male, who presented with spontaneous pneumomediastinum and subcutaneous emphysema unrelated to high-pressure ventilatory measures, detected on chest computed tomography (CT). Despite acute medical care, the patient progressed towards a more serious clinical course. Male gender and diffuse alveolar damage caused by COVID-19 seems to be the most relevant association in this case. However, we have enlightened other possible pathological mechanisms and their association with severity index of COVID-19.

Different presentation of pulmonary parenchymal disruption in COVID-19 pneumonia. Case series of Sub-Intensive Care Unit in Naples, Italy.

The coronavirus disease 2019 (COVID-19) is a recent pandemic that affected more than 5 million people worldwide. Chest high resolution computed tomography (HRCT) is an essential tool in diagnosis and management of the disease. Pulmonary parenchymal opacity is a typical sign of the disease, but not the only one. Pneumothorax, pneumomediastinum, bronchiectasis and cysts are probably underrated complications of COVID-19 that can worsen prognosis, in terms of prolonged hospitalization and need of oxygen therapy. In our single center case series, we outline four different manifestations of pneumothorax, pneumomediastinum and cysts in hospitalized patients with COVID-19 pneumonia.

A case report of pneumomediastinum and subcutaneous emphysema associated with pandemic COVID-19 in a 43-year-old man.

COVID-19 is a newly emerging disease with high mortality among the elderly and patients with underlying medical conditions. We report the case of confirmed COVID-19 infection complicated with pneumomediastinum.

COVID-19 with spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema in the intensive care unit: Two case reports.

Real-Time-reverse-transcription-Polymerase-Chain-Reaction from nasopharyngeal swabs and chest computed tomography (CT) depicting typically bilateral ground-glass opacities with a peripheral and/or posterior distribution are mandatory in the diagnosis of COVID-19. COVID-19 pneumonia may present though with atypical features such as pleural and pericardial effusions, lymphadenopathy, cavitations, and CT halo sign. In these two case-reports, COVID-19 presented as pneumothorax, pneumomediastinum and subcutaneous emphysema in critically ill patients. These disorders may require treatment or can be even self-limiting. Clinicians should be aware of their potential effects on the cardiorespiratory status of critically ill COVID-19 patients. Finally, pneumothorax can be promptly diagnosed by means of lung ultrasound. Although operator dependent, lung ultrasound is a useful bedside diagnostic tool that could alleviate the risk of cross-infection related to COVID-19 patient transport.

Pneumomediastinum and subcutaneous emphysema after noninvasive ventilation in a COVID-19 patient.

Pneumomediastinum is an uncommon but well recognized complication of both invasive and non-invasive mechanical ventilation. Spontaneous pneumomediastinum has been observed in association with a variety of structural lung diseases including severe interstitial disorders. More recently it has been reported complicating the course of COVID-19 pneumonia. In the present report we describe a case of pneumomediastinum associated with subcutaneous emphysema in a patient with severe respiratory failure due to extensive interstitial pneumoniae correlated to SARS-CoV-2 infection which necessitated non-invasive ventilatory support. Prompt recognition is required during ventilatory support as it may promote its progression. Further data are needed in order to identify the mechanisms, frequency, risk factors and prognostic role of this rare complication of the clinical course of COVID-19.

Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19: case report and literature review.

Coronavirus Disease 2019 (COVID-19) has rapidly spread worldwide. Numerous studies have shown its typical and atypical CT findings. We report one COVID-19 patient who presented with a transient pneumothorax, spontaneous pneumomediastinum (SP), as well as subcutaneous emphysema during hospitalization. Chest CT andclinical findings were discussed, and a literature review is presented. The probable cause of SP in COVID-19 was alveolar damage. Once pneumothorax and SP were present, the patient should be carefully monitored to prevent respiratory deterioration, especially when lung lesions are severe.

Spontaneous pneumothorax and subcutaneous emphysema in COVID-19 patient: Case report.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome virus coronavirus 2 (SARS-CoV-2). As known, COVID-19 has become a global pandemic and serious health problem. Disease mainly affects lungs and common findings are fever cough and shortness of breath. Computerized tomography (CT) has an important role in initial evaluation and follow up of COVID-19. Main (CT) finding of the disease is bilateral extensive ground-glass opacification (GGO) with a peripheral or posterior distribution, mainly involving the lower lobes. In this case report, we present a pneumothorax and subcutaneous emphysema case in a patient with COVID-19. To the best of authors' knowledge, it is the first illustrated case of pneumothorax accompanying COVID-19 pneumonia.