Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?

Lemmers, Daniel H.L.; Hilal, Mohammed Abu; Bnà, Claudio; Prezioso, Chiara; Cavallo, Erika; Nencini, Niccolò; Crisci, Serena; Fusina, Federica; Natalini, Giuseppe

doi:10.1183/23120541.00385-2020

Cited by 132 publications

(213 citation statements)

References 18 publications

(13 reference statements)

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“…Indeed, a recent worldwide observational study evaluating the incidence and characteristics of ARDS patients in the ICU, described that a tracheostomy was performed in 13% of the overall ARDS population [11], increasing from 9.6% in mild to 14.5% in severe ARDS patients [12]. On the contrary, recent literature regarding COVID-induced ARDS already described an increased use of tracheostomy, in line with our ndings, ranging from 32% up to 60% [13][14][15][16].…”

Section: Discussionsupporting

confidence: 78%

Tracheostomy Practice in Mechanically Ventilated Patients With SARS-CoV-2 Induced Acute Respiratory Distress Syndrome: a Single-center Retrospective Study With Focus on Tracheomalacia

Guarnieri

Andreoni

Gay

et al. 2021

Preprint

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Background: The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare, but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. Aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence.Methods. Retrospective, single-center study performed in an Italian teaching hospital. All adult patients admitted to the Intensive Care Unit (ICU) between February 24 and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, while information regarding airway management was collected daily.Results. A total of 151 patients were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 39.7%. A tracheostomy was performed in 73 (48.3%) patients: open surgical technique in 54 patients (74%) and percutaneous Ciaglia technique in 19 patients (26%). Patients in whom a tracheostomy was performed had, compared to the other patients, a longer duration of mechanical ventilation and longer ICU and hospital length of stay. Tracheomalacia was diagnosed in 8 (5%) patients. The factors associated with tracheomalacia were female sex, obesity, and tracheostomy.Conclusions. In our population, approximately 50% of patients with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized patients had a longer ICU and hospital length of stay. Five percent of our population was diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature and the underlying mechanisms are not fully understood.

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Section: Discussionsupporting

confidence: 78%

Tracheostomy Practice in Mechanically Ventilated Patients With SARS-CoV-2 Induced Acute Respiratory Distress Syndrome: a Single-center Retrospective Study With Focus on Tracheomalacia

Guarnieri

Andreoni

Gay

et al. 2021

Preprint

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“…The rates of barotrauma are significantly higher than those reported in prior reports of ARDS of other etiologies but similar to other viral ARDS. [7] The barotrauma was seen in both NIV and iMV, though patients on iMV had a higher incidence (11% in iMV vs. 8.1% in the NIV group). The barotrauma occurred despite the use of standard ARDS ventilatory strategies (6-8ml/Kg tidal volume and plateau pressure < 30 cm H2O) in the iMV group and similar TV targets in the NIV group.…”

Section: Discussionmentioning

confidence: 99%

“…The median P/F ratio in the 23 C-ARDS with barotrauma was 105 (IQR 81, 137) compared with 114 (IQR 86, 153) in regular ARDS. [7]…”

Section: Discussionmentioning

confidence: 99%

“…These findings are consistent with prior reports of similar effects noted with other coronavirus infections, including SARS-CoV1 and MERS-CoV ARDS. [7-9] Finally, this aspect of elevated D-dimer with thrombosis also complicated management as ICD tubes had to inserted in the presence of therapeutic anticoagulation with an enhanced bleeding risk.…”

Section: Discussionmentioning

confidence: 99%

“…The median P/F ratio in the 23 C-ARDS with barotrauma was 105 (IQR 81, 137) compared with 114 (IQR 86, 153) in regular ARDS. [7] In terms of pulmonary vascular involvement, COVID-19 ARDS is associated with pulmonary vascular micro/macro-thrombi formation, with an increased risk of pulmonary thromboembolism and pulmonary infarction. [15] These thrombotic events have been postulated to cause necrosis and damage to the preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted February 16, 2021. ; https://doi.org/10.1101/2021.02.12.21251479 doi: medRxiv preprint Our study has several limitations.…”

Section: Lemmers Et Al Described a Barotrauma Incidence Of 23 Out Of mentioning

confidence: 99%

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Severe COVID-19 pneumonia and barotrauma: From the frying pan into the fire

Kalpakam¹,

Bansal²,

Suresh³

et al. 2021

Preprint

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Aim: COVID-19 pneumonia with ARDS (C-ARDS) has a high mortality. Preliminary reports indicate a higher incidence of barotrauma in patients with C-ARDS[1] both on invasive mechanical ventilation (iMV) and non-invasive ventilation (NIV) This study examines the incidence and risk factors for barotrauma and change in outcomes after barotrauma in patients with severe C-ARDS on positive pressure respiratory support (PPRS). Methods and materials: This is a retrospective study of C-ARDS associated barotrauma over 5 months in patients on PPRS in a tertiary COVID care center. The type of barotrauma, intervention, related factors, such as type of respiratory support (iMV vs NIV), airway pressure prior to the occurrence of barotrauma, and post-barotrauma outcomes were analyzed. Results: A total of 38/410 (9.3%) C-ARDS patients on PPRS [mean age 57.82 +/- 13.3(SD) years, 32 males (84.2%)] developed barotrauma. Of these, 20 patients (52.6%) were on NIV and 18 (47.4%) patients were iMV on standard recommended settings. The median P/F ratio of patients on MV at the time of barotrauma was 116.4 (IQR 72.4, 193.25). The details of barotrauma were as follows: 24 patients had pneumothorax (PTX), 2 had pneumo-mediastinum and 12 had subcutaneous emphysema. Overall, 24/38 (63.2%) patients, including 15/18 (83.3%) on MV succumbed to their illness. The barotrauma happened a median of 6.5 days (IQR 4.75,13) after admission and 15 days (IQR 10.25,18.0) from symptom onset. The median duration from barotrauma to death was 7 days (IQR 2.25, 8.0) and barotrauma to discharge (for survivors) was 12.5 days (IQR 8.0, 21.25). All patients received steroids and 11/38 (28.9%) received additional immunosuppression with tocilizumab. Conclusion: A high incidence of barotrauma was seen in this large series of severe C-ARDS patients on PPRS. Barotrauma led to further deterioration in the clinical status leading to a fatal outcome in the majority of the MV patients, despite prompt treatment.

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Young convalescent COVID‐19 pneumonia with extensive pneumomediastinum emphysema: Case report

Jagosz

Guzik

Moczała

et al. 2022

Clinical Case Reports

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Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?

Cited by 132 publications

References 18 publications

Tracheostomy Practice in Mechanically Ventilated Patients With SARS-CoV-2 Induced Acute Respiratory Distress Syndrome: a Single-center Retrospective Study With Focus on Tracheomalacia

Tracheostomy Practice in Mechanically Ventilated Patients With SARS-CoV-2 Induced Acute Respiratory Distress Syndrome: a Single-center Retrospective Study With Focus on Tracheomalacia

Severe COVID-19 pneumonia and barotrauma: From the frying pan into the fire

Young convalescent COVID‐19 pneumonia with extensive pneumomediastinum emphysema: Case report

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