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COVID-19 ventilator barotrauma management: less is more.
Housman, Brian; Jacobi, Adam; Carollo, Andrea; Nobel, Tamar; Eber, Corey; Acquah, Samuel; Powell, Charles; Kaufman, Andrew; Lee, Dong-Seok; Nicastri, Daniel; Hakami, Ardeshir; Song, Kimberly; Kohli-Seth, Roopa; Flores, Raja.
  • Housman B; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Jacobi A; Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Carollo A; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Nobel T; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Eber C; Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Acquah S; Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Powell C; Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Kaufman A; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Lee DS; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Nicastri D; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Hakami A; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Song K; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Kohli-Seth R; Surgery, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
  • Flores R; Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
Ann Transl Med ; 8(23): 1575, 2020 Dec.
Article in English | MEDLINE | ID: covidwho-1006759
ABSTRACT

BACKGROUND:

COVID-19 patients requiring mechanical ventilation may develop significant pneumomediastinum and sub-cutaneous emphysema without associated pneumothorax (SWAP). Prophylactic chest tube placement or sub-fascial "blowholes" are usually recommended to prevent tension pneumothorax and clinical decline. Risk of iatrogenic lung injury and release of virus into the environment is high. Incidence and conservative management data of such barotraumatic complications during the COVID-19 pandemic are lacking.

METHODS:

All patients with mediastinal air and SWAP evaluated by the department of Thoracic Surgery at the Mount Sinai Hospital between March 30 and April 10, 2020 were identified. All patients without pneumothorax were treated conservatively with daily chest x-ray and observation. Three patients had prophylactic chest tube placement prior to the study period without thoracic surgery consultation.

RESULTS:

There were 29 cases of mediastinal air with SWAP out of 171 COVID positive intubated patients (17.0%) who were treated conservatively. Patients were intubated for an average of 2.4 days before SWAP was identified. 12 patients (41%) had improvement or resolution without intervention. Two patients progressed to pneumothorax 3 and 8 days following initial presentation. Both had chest tubes placed without incident before there were any changes in oxygenation, hemodynamics, supportive medications, or ventilator settings. There were 3 patients who had percutaneous tubes placed before the study period all of whom had significant worsening of their sub-cutaneous air and air leak.

CONCLUSIONS:

Conservative management of massive sub-cutaneous emphysema without pneumothorax in COVID-19 patients is safe and limits viral exposure to healthcare workers. Placement of chest tubes is discouraged unless a definite sizable pneumothorax develops.
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Full text: Available Collection: International databases Database: MEDLINE Type of study: Experimental Studies / Observational study / Prognostic study Language: English Journal: Ann Transl Med Year: 2020 Document Type: Article Affiliation country: Atm-20-3907

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Full text: Available Collection: International databases Database: MEDLINE Type of study: Experimental Studies / Observational study / Prognostic study Language: English Journal: Ann Transl Med Year: 2020 Document Type: Article Affiliation country: Atm-20-3907