High Incidence of Barotrauma in Patients With Severe Coronavirus Disease 2019

Abstract

Objective.: To report the high incidence of barotrauma in critically ill patients admitted to the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19) and to discuss its implications. Design.: Retrospective cohort study. Setting.: ICU of an academic county hospital in Los Angeles, CA admitted from March 15-June 20, 2020. Patients.: 77 patients with COVID-19 pneumonia. 75 patients met inclusion criteria. Results.: 21% of patients with severe COVID-19 sustained barotrauma (33% of patients receiving IMV, 8% of patients receiving (NIV). There were no differences between the barotrauma and non-barotrauma groups regarding demographics, illness severity, or medications received, nor tidal volume or average/peak airway pressures in those receiving IMV. In the barotrauma group there was a greater proportion of patients receiving therapeutic anticoagulation (81% vs. 47%, p = 0.023) and ventilated using airway pressure release ventilation mode (13% vs. 0%, p = 0.043). Barotrauma was associated with increased likelihood of receiving a tracheostomy (OR 2.58 [0.23-4.9], p = 0.018]), longer median ICU length of stay (17 days vs. 7 days, p = 0.03), and longer median length of hospitalization (26 days vs. 14 days, p < 0.001). There was also a trend toward prolonged median duration of IMV (12.5 days vs 7 days, p = 0.13) and higher average mortality (56% vs 37%, p = 0.25). Conclusions.: Barotrauma is seen in 5-12% of patients with ARDS receiving IMV and is exceedingly rare in patients receiving NIV. We report a high incidence of barotrauma observed in critically ill patients with COVID-19 requiring either NIV or IMV. While there was a trend toward increased mortality in patients with barotrauma, this did not reach statistical significance. The increased incidence of barotrauma with COVID-19 may be a product of the pathophysiology of this disease state and a heightened inflammatory response causing rampant acute lung injury. Evidence-based medicine and lung-protective ventilation should remain the mainstay of treatment.

Outcomes of Barotrauma in Critically Ill COVID-19 Patients With Severe Pneumonia

“… 3 , 4 , 6 , 7 Similarly, a recent publication by Kahn et al demonstrated no difference in tidal volume or average/peak airway pressures in patients with COVID-19 receiving invasive mechanical ventilation between those with barotrauma and those without barotrauma. 21 While the underlying pathological mechanisms of PM or PTX in COVID-19 patients has yet to be fully elucidated, a widely postulated mechanism is that the severe and prolonged inflammation caused by the SARS-COV-2 virus leads to a widespread destruction of alveoli and airspace, increasing the likelihood of rupture with slight pressure changes from Valsalva maneuvers or mechanical ventilation. 22 , 23 These mechanisms may explain the possible increased incidence of barotrauma complications associated with mechanically ventilated COVID-19 patients.…”

A radiological predictor for pneumomediastinum/pneumothorax in COVID-19 ARDS patients

“…COVID-19 ARDS patients are thought to be indeed more vulnerable to PMD/PNX occurrence as compared with patients with ARDS due to other than COVID-19 causes [ 1 , 3 ]; a higher than expected incidence of PMD/PNX was also observed in COVID-19 patients not requiring invasive mechanical ventilation [ [3] , [4] , [5] , [6] ]. Furthermore, despite employment of lung protective ventilation strategies, these complications have difficult, non-standardized management, and are associated with increased risk of mortality [ 2 , 7 , 8 ]. Taken together, these findings corroborate the existence of a virus-induced frailty of airways tissue, resulting in an extensive, COVID-19-specific diffuse alveolar damage; microvascular thrombosis [ 9 ], interstitial inflammation, as well as endothelial barrier disruption have been suggested as main contributors for such a condition [ 10 ].…”

Pneumothorax and barotrauma in invasively ventilated patients with COVID-19

“…On the contrary, among 160 randomly selected invasively ventilated COVID-19 patients without pneumothorax, mortality was 78/ 160 (49 %).We recently published a systematic review on rate of barotrauma among invasively ventilated COVID-19 patients [2]. Our pooled analysis included data from 13 studies and 1814 patients [3][4][5][6][7][8][9][10][11][12][13][14][15] and we found that pooled estimate of pneumothorax rate was 10.7 % (95 % confidence interval [CI] = 6.7 %-14.7 %), while overall rate of barotrauma event was 16.1 % (95 % CI = 11.8 %-20.4 %). In addition, we found an overall mortality rate for COVID-19 patients who developed barotrauma of 61.6 % (95 % CI = 50.2 %-73.0 %), as compared with a mortality of 49.5 % (95 % CI = 41.1 %-58.0 %) for COVID-19 patients who did not develop barotrauma.We are pleased to read that our findings are further reinforced by another study, that confirms that pneumothorax rate among mechanically ventilated COVID-19 patients is between 10 and 15 %.…”

“…We recently published a systematic review on rate of barotrauma among invasively ventilated COVID-19 patients [2]. Our pooled analysis included data from 13 studies and 1814 patients [3][4][5][6][7][8][9][10][11][12][13][14][15] and we found that pooled estimate of pneumothorax rate was 10.7 % (95 % confidence interval [CI] = 6.7 %-14.7 %), while overall rate of barotrauma event was 16.1 % (95 % CI = 11.8 %-20.4 %). In addition, we found an overall mortality rate for COVID-19 patients who developed barotrauma of 61.6 % (95 % CI = 50.2 %-73.0 %), as compared with a mortality of 49.5 % (95 % CI = 41.1 %-58.0 %) for COVID-19 patients who did not develop barotrauma.…”