PULMONARY BAROTRAUMA DURING NONINVASIVE VENTILATION IN PATIENTS WITH COVID-19

ABSTRACT

SESSION TITLE Chest Infections Posters SESSION TYPE Original Investigation Posters PRESENTED ON October 18-21, 2020 PURPOSE: The pathophysiology of respiratory distress in hospitalized patients with COVID-19 is not yet fully understood. Spontaneous pulmonary barotrauma (PBT) is a pulmonary complication typically seen in intubated patients. However, in the related viral epidemic of SARS in 2002, 6.6% to 15% of patients on non-invasive ventilation (NIV) were described to have developed PBT, with severe alveolar destruction as the suggested mechanism. Within the COVID-19 pandemic, isolated case studies have described bulla and PBT, and a systematic review of imaging has suggested PBT to be a sign of disease progression. METHODS: In this single center retrospective case series, two patients with confirmed COVID-19 infection who developed PBT on NIV were identified in a New York City hospital from March 2020 to April 2020 and were included in this study. RESULTS: Both the patients were non-smokers with no pre-existing lung disease. The first patient was a 58-year-old woman with a history of pemphigus vulgaris, and the second patient was a 69-year-old man with a history of hypertension and type 2 diabetes mellitus. Both patients received treatment with hydroxychloroquine, azithromycin, therapeutic anticoagulation, high dose steroids, and were enrolled in the hospital’s remdesivir trial. Both patients required oxygen therapy which included escalation from nasal cannula to continuous positive airway pressure (CPAP), and both were encouraged to self-prone. The first patient was found to have a large left pneumothorax (PTX), pneumomediastinum (PM), and extensive subcutaneous emphysema (SE) on day 18 of hospitalization while on CPAP of 12 cm H2O, requiring surgical chest tube placement. The second patient developed a small left apical PTX, PM, and SE on day eight of hospitalization while on CPAP of 14 cm H2O, which was conservatively managed. Both patients eventually required intubation for worsening hypoxemia and later succumbed to their illness. CONCLUSIONS: In this study we identified two patients who developed PBT without being subjected to invasive ventilation or very high levels of PEEP. Both patients had poor outcomes, suggesting that COVID-19 may be associated with alveolar destruction, especially in the setting of steroid use. Glucocorticoid use may interfere with lung healing which could further increase the risk of alveolar rupture. CLINICAL IMPLICATIONS This study encourages clinicians to have low threshold to suspect PBT in COVID-19 patients even while on NIV. Prospective studies are needed further to determine the utility of steroid use, given this potential risk for PBT and the clinical significance of our observations in COVID-19 patients. DISCLOSURES No relevant relationships by Kirtipal Bhatia, source=Web Response No relevant relationships by Joseph Ghassibi, source=Web Response No relevant relationships by Julia Goldberg, source=Web Response No relevant relationships by Yasmin Herrera, source=Web Response No relevant relationships by Kam Sing Ho, source=Web Response No relevant relationships by Vivek Modi, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response