Surgical management of tension pneumomediastinum in mechanically ventilated coronavirus disease 2019 patients.

INTRODUCTION: Tension pneumomediastinum is an increasingly common condition since the COVID-19 pandemic's onset. It is a life-threatening complication with severe hemodynamic instability that is refractory to catecholamines. Surgical decompression with drainage is the key point of treatment. Various surgical procedures are reported in the literature, but no cohesive approach has yet been developed. AIM: The aim was to present the available options for surgical treatment of tension pneumomediastinum, as well as the post-interventional results. MATERIALS AND METHODS: Nine cervical mediastinotomies were performed on intensive-care unit (ICU) patients who developed a tension pneumomediastinum during mechanical ventilation. The age and sex of patients, surgical complications, pre- and post-intervention basic hemodynamic parameters, as well as oxygen saturation levels, were recorded and analyzed. RESULTS: The mean age of patients was 62±16 years (6 males and 3 females). No postoperative surgical complications were recorded. The average preoperative systolic blood pressure was 91±12 mmHg, the heart rate was 104±8 bpm, and the oxygen saturation level was 89±6%, while the short-term postoperative values changed to 105±6 mmHg, 101±4 bpm, and 94±5%, respectively. There was no long-term survival benefit, with a mortality rate of 100%. CONCLUSIONS: Cervical mediastinotomy is the operative method of choice in the presence of tension pneumomediastinum allowing an effective decompression of the mediastinal structures and improving the condition of the affected patients without improving the survival rate.

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.

Surgical treatment of tension pneumomediastinum in patients with covid-19 at the field hospital: a case series.

BACKGROUND: Tension pneumomediastinum is one of the most serious complications in COVID-19 patients with respiratory distress requiring invasive mechanical ventilation. This complication can lead to rapid hemodynamic instability and death if it is not recognized in a timely manner and intervenes promptly. CASE PRESENTATION: We reported 7 COVID-19 patients with tension pneumomediastinum at a field hospital. All patients were critically ill with ARDS. These 7 patients, including 3 females and 4 males in this series, were aged between 39 and 70 years. Tension pneumomediastinum occurred on the first day of mechanical ventilation in 3 patients and later in the course of hospital stay, even 10 days after being intubated and ventilated. The tension pneumomediastinum caused hemodynamic instability and worsened respiratory mechanics with imminent cardiopulmonary collapse. In this series, we used two surgical techniques: (i) mediastinal decompression by suprasternal drainage with or without simultaneous pleural drainage in the first two cases and (ii) mediastinal drainage via suprasternal and subxiphoid incisions in 5 patients. The surgical procedures were feasible and reversed the pending cardiopulmonary collapse. Four patients had a favorable postprocedural period and were discharged from the intensive care center. Both patients undergoing suprasternal drainage died of failed/recurrent tension pneumomediastinum and nosocomial infection. Only one in five patients who underwent mediastinal drainage via suprasternal and subxiphoid incisions died of septic shock secondary to ventilator-associated pneumonia. CONCLUSION: Tension pneumomediastinum was a life-threatening complication in critically ill COVID-19 patients requiring mechanical ventilation. Surgical mediastinal decompression was the salvage procedure. The surgical technique of mediastinal drainage via suprasternal and subxiphoid incisions proved an advantage in tension relief, hemodynamic improvement and mortality reduction.

Bedside Mediastinotomy for Tension Pneumomediastinum With Tamponade in COVID-19.

Tension pneumomediastinum is a rare but life-threatening cause of tamponade. Mechanical ventilation is a described source of tension pneumomediastinum. Here, we present a case of a 72-year-old man who developed cardiovascular collapse from tension pneumomediastinum in the setting of coronavirus disease 2019-related acute respiratory distress syndrome. We successfully performed bedside mediastinotomy and mediastinal tube placement under local anesthetic to alleviate his hemodynamic instability. Bedside mediastinotomy can be used to relieve tension pneumomediastinum in this setting.

Bedside Transcervical-Transtracheal Postintubation Injury Repair in a COVID-19 Patient.

Severe acute respiratory syndrome coronavirus 2 disease 2019 (COVID-19) has rapidly spread worldwide since December 2019. An acute respiratory distress syndrome develops in a relevant rate of patients, who require hospitalization. Among them, a nonnegligible rate of 9.8% to 15.2% of patients requires tracheal intubation for invasive ventilation. We report the case of a pneumomediastinum and subcutaneous emphysema developing in a COVID-19 patient secondary to postintubation tracheal injury. The management of COVID-19 patients can be challenging due to the risk of disease transmission to caregivers and epidemic spread. We performed a bedside tracheal injury surgical repair, after failure of conservative management, with resolution of pneumomediastinum and subcutaneous emphysema and improvement of the patient's conditions.