Spontaneous mediastinal emphysema in a non-intubated patient with COVID-19 related pneumonia: a case report.

Spontaneous mediastinal emphysema (ME) is a rare clinical entity often associated with sudden changes in intrathoracic pressures. The presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. Inflammatory alterations installed over the airway following SARS-CoV-2 infection may reduce its distensibility and compliance conferring an increased risk of developing the complication, even in the absence of mechanical ventilation. However, the exact mechanism by which ME occurs in SARS-CoV-2 pneumonia is unknown. We report a case of a 58-year-old man that presented to the emergency department with dyspnea, subcutaneous emphysema of the neck and high clinical suspicion of COVID-19 infection. There was no smoking history and no lung comorbidities. The patient was admitted into a monitored unit and received management accordingly (having never required mechanical intubation). During chest radiological evaluation ME was found and ultimately resolved with noninvasive maneuvers. We want to emphasize the importance of this adverse event despite their non-smoking history and the exclusion of positive pressure ventilation. Given the recent increase in the number of patients with COVID-19 related pneumonia, the presence of pneumomediastinum in patients with COVID-19 infection should alert the clinician to monitor the patients carefully for possible worsening of disease, especially when lung lesions are severe.

Lung necrosectomy in pediatric patients with necrotizing pneumonia.

INTRODUCTION: Necrotizing pneumonia is the consolidation of lung parenchyma with destruction and necrosis, forming solitary or multiloculated radiolucent foci. When antibiotic treatment fails and clinical course does not improve, patients might need lung tissue resection: segmentectomy, lobectomy or bilobectomy. We have performed a more conservative surgical approach in pediatric patients with necrotizing pneumonia, lung necrosectomy: resection of unviable necrotic tissue, to preserve more healthy and potentially recoverable lung parenchyma. The objective of this study is to present the results of our experience with lung necrosectomy. METHODS: Retrospective review of clinical charts of children with necrotizing pneumonia. The diagnosis was based on physical examination, laboratory data and contrast CT scan. Lung necrosectomy technique includes resection of necrotic tissue with careful debridement technique; air leaks were sutured and/or tissue imbrication. RESULTS: Twenty-four children were surgically treated for necrotizing pneumonia (18 girls and 6 boys). The mean age was 31.5 ± 13.5 months. All the patients presented productive cough, fever and dyspnea; chest X-rays showed consolidated areas with intraparenchymal cavities and hypoperfusion on the contrasted CT. Surgical treatment included: Lung necrosectomy 17 (70%); lobectomy 3 (12.5%); wedge resection 2 (8.3%); lobectomy + lung necrosectomy 1 (4.1%), and wedge resection + lung necrosectomy 1 (4.1%). The postoperative course was uneventful in 23 patients; mean postoperative hospital stay was 6.3. One patient died because of sepsis. CONCLUSIONS: Lung necrosectomy is a conservative, effective surgical treatment, which solves lung necrotizing infection avoiding resection of healthy lung parenchyma.