Barotrauma among patients with COVID-19 ARDS versus historical ARDS

ABSTRACT

RATIONALE Multiple case reports and case series have described pneumothorax and pneumomediastinum as a complication of patients hospitalized with COVID-19, particularly among those receiving invasive mechanical ventilation. However, it is not known whether patients with COVID-19 have a uniquely higher incidence of these events compared to historical ARDS (non-COVID-19 ARDS) patients. METHODS We compared barotrauma rates in patients hospitalized with COVID-19 who received invasive mechanical ventilation between March-July 2020 to patients with non-COVID-19 ARDS who received mechanical ventilation in 2016-2018. We defined barotrauma as pneumothorax or pneumomediastinum during mechanical ventilation. RESULTS We analyzed 222 patients with COVID-19 who received invasive mechanical ventilation and 421 patients with ARDS. Barotrauma events occurred in 13.1% of patients with COVID-19 and 9.3% of historical ARDS patients (p = 0.136). Mean tidal volumes were 5.7 and 6.4 mL/kg of predicted body weight, plateau pressures were 25.6 and 23.6, PEEP was 11.2 and 8.8, and driving pressures were 14.4 and 14.8 cmH2O, respectively, in COVID-19 and non-COVID-19 ARDS. There were 42 pneumothoraces among COVID-19 patients and 50 among historical ARDS patients (p = 0.144). Incidence rates were 1.7 and 2.7 per 100 ventilator days in COVID-19 and historical ARDS respectively (p=0.808). There were 14 cases of pneumomediastinum among patients with COVID-19 compared to 16 among patients with ARDS (p = 0.152). Overall, pneumothoraces were identified within 24 hours of ipsilateral internal jugular or subclavian line placement in 5.4% (5/92) of events. In both groups, barotrauma was associated with fewer vent-free days at 28 days (3.0 vs 9.2 in COVID-19, p < 0.001 and 7.6 vs 11.5 in historical ARDS, p = 0.0214). Barotrauma was not associated with an increased mortality at discharge for either cohort. For COVID-19 patients only, mean plateau pressure and driving pressure were associated with barotrauma events (28 vs 25 cmH2O, p = 0.0015;16.7 vs 14.0 cmH2O, p ≤ 0.01). Administered tidal volume, PEEP, age, sex, tobacco use, obesity, number of comorbidities, and the presence of lung comorbidities were not associated with barotrauma in either cohort. CONCLUSIONS Both COVID-19 and non-COVID-19 ARDS patients who are mechanically ventilated are at high risk of barotrauma;this was not unique to patients with COVID-19. Barotrauma is associated with prolonged ventilation and fewer ventilator-free days. Despite advances in lung-protective ventilation, barotrauma continues to be a significant source of morbidity in patients mechanically ventilated for respiratory failure.