PNEUMOMEDIASTINUM IN A CRITICALLY ILL CORONAVIRUS DISEASE 2019 (COVID-19) PATIENT

ABSTRACT

SESSION TITLE Fellows Critical Care Posters SESSION TYPE Fellow Case Report Posters PRESENTED ON October 18-21, 2020 INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) pandemic has displayed heterogeneity in disease manifestations and complications;cardiac, renal, neurological complications and coagulopathy are reported. We present a case of COVID-19 with pneumomediastinum. CASE PRESENTATION A 59-year-old male was admitted after a reverse transcriptase polymerase chain reaction (RT-PCR) test- confirmed COVID19. He was confused and was intubated for hypoxia. Laboratory investigation showed white blood cells of 2.8x1000/mm3 (normal 3.4-9.4x1000/ mm3) [differential 59%(normal 47-67%) neutrophils and 39% ( normal 25-45%) lymphocytes], aspartate aminotransferase 1174 IU/l(normal13-39IU/l), alanine aminotransferase 598 IU/l(normal7-52IU/l), ferritin > 7500 ng/ml (normal 20-200 ng/ml), C reactive protein 306.1 mg/l (normal 0-5 mg/l) and D-dimer 10 mcg/ml (normal 0-0.50 mcg/ml). Arterial blood gases showed pH 7.14 (normal 7.35-7.45), PCO2 59 mmHg (normal 34-46 mmHg) and PO2 54 mmHg (normal 80-97 mmHg) on 100% oxygen. Computed tomography of the chest (CT chest) showed diffuse groundglass opacities. Diagnosis of acute respiratory distress syndrome (ARDS) was made. On day 5, given low lung compliance (static compliance 13.5 ml/CmH2O), mode was switched to airway pressure release ventilation(APRV). On day 8, subcutaneous emphysema was noted with worsening hemodynamics. CT chest showed pneumomediastinum, pneumopericardium and subcutaneous air without pneumothorax. APRV was changed to conventional mode and infraclavicular incisions completed. Patient‘s status continued to decline;he died on the 13th day of admission. DISCUSSION: COVID-19 causes pulmonary involvement ranging from atypical pneumonia to ARDS. Few cases of COVID-19-associated pneumomediastinum are reported in the literature. Barotrauma from mechanical ventilation accounts for one third cases of pneumomediastinum. Although, large tidal volumes are thought to predispose to barotrauma, these associations are related to the severity of lung disease. ARDS is most associated and is the only independent risk factor for barotrauma[1]. APRV does not demonstrate any difference regarding the onset of barotrauma when compared to conventional modes used in ARDS[2]. Different pathological patterns ranging from interstitial lymphocytic infiltrates to organizing pneumonia to diffuse alveolar damage are reported in COVID-19[3]. These possibly define the spectrum of COVID-19 and hence the increasing rate of severe complications with worsening injury. CONCLUSIONS: COVID-19 patients display diverse complications;pneumomediastinum is an emerging one. Further research is needed to study COVID-19 and barotrauma within the clinical and pathological phenotypes of the disease. Reference #1 Airway pressures and early barotrauma in patients with acute lung injury and acute respiratory distress. Eisner MD, Thompson BT, Schoenfeld D, et al. Am J Respir Crit Care Med. 165978-982 2002. Reference #2 Airway pressure release ventilation during acute hypoxemic respiratory failure a systematic review and meta-analysis of randomized controlled trials. Carsetti et al. Ann. Intensive Care (2019) 944. Reference #3 Time to consider histologic pattern of lung injury to treat critically ill patients with COVID-19 infection. Marie-Christine Copin, Erika Parmentier, […], and The Lille COVID-19 ICU and Anatomopathology Group. Intensive Care Med. 2020 Apr 231–3. DISCLOSURES No relevant relationships by Moses Hayrabedian, source=Web Response No relevant relationships by Faraaz Nayeemuddin, source=Web Response No relevant relationships by Rajagopal Sreedhar, source=Admin input