Intrathoracic gas effusions in patients with COVID-19.

Current evidence suggests that intrathoracic gas effusions (pneumomediastinum and pneumothorax) may be observed among COVID-19 patients even without mechanical ventilation. Here, we report 9 patients who developed spontaneous intrathoracic gas effusions in the absence of mechanical ventilation. The incidence of spontaneous intrathoracic gas effusions is low at 0.5% in hospitalized COVID-19 patients in the absence of respiratory support. Two patients (22.2%) had spontaneous pneumomediastinum, with or without subcutaneous emphysema. Three patients (33.3%) had pneumomediastinum associated with pneumothorax, with or without subcutaneous emphysema, and 4 patients (44.4%) had spontaneous pneumothorax. The Pneumothorax was unilateral in 66.6% of cases (6/9) but without location preference. Five of our patients were smokers, of whom 80% had isolated spontaneous pneumothorax. Other comorbidities included pulmonary tuberculosis in a single patient, diabetes in 2 patients and arterial hypertension in 1 patient. None of the patients had respiratory comorbidities. All of our patients were male. The average duration of hospital stay was 10 days (±6.63). All patients required oxygen therapy. Three patients (33.3%) with spontaneous pneumothorax required chest drainage. The evolution was favorable in 6 patients (66.7%) and worse in 3 cases (33.3%). The respiratory manifestations of COVID-19 have been stereotyped. Intrathoracic effusions may also be signs of COVID-19 with varying prognoses, or even the only presentation of the disease. This should be considered in clinical practice, and doctors are encouraged to request a SARS-CoV-2 test in this situation. Further investigations with a larger sample size are needed to identify the prognostic factors in COVID-19 patients with gas effusions.

Massive Spontaneous Pneumomediastinum-A Form of Presentation for Severe COVID-19 Pneumonia.

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.

Pneumomediastinum and air leaks secondary to COVID-19: Expectant vs. invasive management of a rare complication.

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.

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.

Tracheomediastinal emphysema after tracheostomy in a post-COVID-19 patient: a case report.

OBJECTIVE: There are no reports of tracheomediastinal fistula development after tracheostomy. CASE REPORT: A 72-year-old female patient with post acute COVID-19 was transferred to our intensive care unit. After two unsuccessful weaning attempts, a tracheostomy was performed at hospitalization on day 32. The patient's body mass index was 35 kg/m2 and she had a narrow neck anatomy. A percutaneous tracheostomy was performed using the Griggs method without any problems. Pneumothorax, pneumomediastinum, subcutaneous emphysema, and hemorrhage were not observed. Twenty-two days after the tracheostomy, the patient developed subcutaneous emphysema and experienced a sudden decrease in oxygen saturation. Bedside anterior-posterior chest X-ray did not detect pneumothorax and a tracheoesophageal fistula was found via esophageal endoscopy. A tracheomediastinal fistula was observed just below the cannula distal end via computed tomography. CONCLUSIONS: There are multiple reasons why a tracheomediastinal fistula could develop after tracheostomy. Therefore, this condition should be considered in cases of sudden subcutaneous emphysema and oxygen deterioration following tracheostomy.

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.

Negative pressure therapy as a safe alternative in the treatment of massive subcutaneous emphysema in critically ill patients COVID-19.

Many surgical treatments have been described for massive subcutaneous emphysema (MSE) over the recent years. However, there is no consensus on which is the most recommended and there is great diversity in treatment. With new advances in minimally invasive therapy performed at the bedside, especially in intensive care units, it has been possible to increase therapeutic efficacy. During the COVID-19 pandemic, some therapeutic techniques have been discussed in critically ill patients with SARS-COV-2 respiratory infections, because of the potential overexposure of healthcare personnel to an increased risk of contagion after direct exposure to air trapped in the subcutaneous tissue of infected patients. We present the clinical case of an 82-year-old male patient, SARS COV-2 infected, with MSE after 48 h with invasive mechanical ventilation in critical intensive care. He was treated with negative pressure therapy (NPT) allowing effective resolution of the MSE in a short period (5 days) with a minimally invasive bedside approach, reducing the potential air exposure of health personnel by keeping the viral load retained by the emphysema. Therefore, we present NPT as an effective, minimally invasive and safe therapeutic alternative to be considered in the management of MSE in critically ill patients infected with SARS COV-2.

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.

Spontaneous pneumomediastinum in COVID-19 patients. Case series.

Spontaneous pneumomediastinum is defined as the presence of free air within the mediastinum without an apparent cause such as chest trauma. It is a benign, self-limiting condition that is conservatively treated. Clinical diagnosis is based on two symptoms: chest pain and dyspnea; and on a particular sign: subcutaneous emphysema. It has been reported in patients with influenza A (H1N1) and severe acute respiratory syndrome; however, it has been rarely observed in COVID-19 patients. In this work, we describe six male patients with COVID-19, aged between 27 and 82 years, who presented with spontaneous pneumomediastinum and subcutaneous emphysema; both conditions were completely resorbed with conservative management.

El neumomediastino espontáneo es la presencia de aire libre en el mediastino sin el antecedente de alguna causa como trauma de tórax. Es una condición benigna autolimitada que se trata en forma conservadora. El diagnóstico clínico se basa en dos síntomas: dolor torácico y disnea; y en un signo en particular: enfisema subcutáneo. Ha sido reportado en pacientes con influenza A (H1N1) y síndrome respiratorio agudo grave; sin embargo, ha sido raramente observado en pacientes con COVID-19. En este trabajo describimos seis pacientes del sexo masculino con COVID-19, con edades entre 27 y 82 años, que presentaron neumomediastino espontáneo y enfisema subcutáneo; ambos se reabsorbieron totalmente con manejo conservador.

Serious complications in COVID-19 ARDS cases: pneumothorax, pneumomediastinum, subcutaneous emphysema and haemothorax.

The novel coronavirus identified as severe acute respiratory syndrome-coronavirus-2 causes acute respiratory distress syndrome (ARDS). Our aim in this study is to assess the incidence of life-threatening complications like pneumothorax, haemothorax, pneumomediastinum and subcutaneous emphysema, probable risk factors and effect on mortality in coronavirus disease-2019 (COVID-19) ARDS patients treated with mechanical ventilation (MV). Data from 96 adult patients admitted to the intensive care unit with COVID-19 ARDS diagnosis from 11 March to 31 July 2020 were retrospectively assessed. A total of 75 patients abiding by the study criteria were divided into two groups as the group developing ventilator-related barotrauma (BG) (N = 10) and the group not developing ventilator-related barotrauma (NBG) (N = 65). In 10 patients (13%), barotrauma findings occurred 22 ± 3.6 days after the onset of symptoms. The mortality rate was 40% in the BG-group, while it was 29% in the NBG-group with no statistical difference identified. The BG-group had longer intensive care admission duration, duration of time in prone position and total MV duration, with higher max positive end-expiratory pressure (PEEP) levels and lower min pO2/FiO2 levels. The peak lactate dehydrogenase levels in blood were higher by statistically significant level in the BG-group (P < 0.05). The contribution of MV to alveolar injury caused by infection in COVID-19 ARDS patients may cause more frequent barotrauma compared to classic ARDS and this situation significantly increases the MV and intensive care admission durations of patients. In terms of reducing mortality and morbidity in these patients, MV treatment should be carefully maintained within the framework of lung-protective strategies and the studies researching barotrauma pathophysiology should be increased.

Case Report: Barotrauma in COVID-19 Case Series.

Severe acute respiratory syndrome coronavirus 2 can cause pulmonary complications, such as increased risk of barotrauma (BT), but its prevalence and risk factors are not known. In this case series, the course of BT and its related risk factors were discussed in patients with COVID-19 who were admitted to the intensive care unit. Medical records of the patients with COVID-19 and BT and hospitalized in the intensive care unit for 5 months were extracted. The course of BT and its possible associated risk factors are descriptively presented. Among 103 patients with COVID-19 who were intubated, 13 patients (12.6%) had BT. One patient developed BT before intubation. All patients with BT were male. Half of them developed BT in the first 5 days of intubation. Eight patients (61.53%) had a positive culture for Klebsiella pneumoniae. Nine patients (69.9%) died. High positive end-expiratory pressure, coinfection with bacterial pneumonia, and history of lung disease may affect BT incidence. The treatment team should increase their upervision on the ventilator setting, especially in the first week of intubation.

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.

Subcutaneous emphysema and pneumomediastinum in patients with COVID-19 disease; case series from a tertiary care hospital in Pakistan.

Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23-75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. Eight out of ten patients had spontaneous pneumomediastinum on their initial chest x-ray in the emergency department. The median duration of assisted ventilation before the development of SE was 5.5 days (interquartile range, 5-10 days). The highest positive end-expiratory pressure (PEEP) was 10 cmH2O for patients recieving invasive mechanical ventilation, while 8 cmH2O was the average PEEP in patients who had developed subcutaneous emphysema on non-invasive ventilation. All patients received corticosteroids while six also received tocilizumab, and seven received convalescent plasma therapy, respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8-25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to COVID-19 triggered by the use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and SE whenever present, is associated with poor outcome in critically ill COVID-19 ARDS patients.