Subcutaneous emphysema and pneumomediastinum in patients with COVID-19 disease: Case series

ABSTRACT

INTRODUCTION: Since its first reported from Wuhan in December 2019, the clinical symptoms of COVID-19 and its complications are still evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema and pneumomediastinum. We report the case series of 10 patients of COVID-19, with subcutaneous emphysema along with pneumomediastinum. METHODS: All patients were admitted to the critical care area from April to June 2020 at Aga Khan University Hospital, Karachi, Pakistan. Electronic records and medical files reviewed for the patient's baseline characteristics, days of ventilation before subcutaneous emphysema, treatment given for COVID-19, cytokine release syndrome (CRS) grade, and with in-hospital mortality. RESULTS: The mean (±SD) age of the patients was 59±8 years (range, 23-97). The majority of them were men (80%), and common symptoms were dyspnea (100%), fever (80%), and cough (80%). None of them had underlying lung disorder. Six patients had hypertension, and five had diabetes. All patients had acute respiratory distress syndrome (ARDS) on admission, with a median PaO2/FiO2 ratio of 122.5. Eight patients with CRS grade III were being managed in high dependency units at the time of development of subcutaneous emphysema, and two with CRS grade IV were treated in ICU. The median duration of assisted ventilation before the development of subcutaneous emphysema was 7 days (interquartile range, 5-10 days). The highest PEEP for invasively ventilated patients was 10, while the CPAP ranged from 12-16, in non-invasive ventilation patients. Eventually, all required intubation. Chest tubes thoracostomy was done in five patients. All received corticosteroids, 6 received tocilizumab, and 7 received convalescent plasma therapy. Seven patients died during their hospital stay. Obstructive shock with tension pneumothorax was the cause of death in 1 patient, while four died of septic shock. Two patients had their ventilator withdrawn due to multiorgan dysfunction syndrome. CONCLUSIONS: High risk COVID-19 patients requiring positive pressure ventilation can develop subcutaneous emphysema and pneumomediastinum. One has to be vigilant about lung-protective ventilator strategies for the management of hypoxia in COVID -19 patients.