Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report

Abstract Background Spontaneous pneumomediastinum unrelated to mechanical ventilation is a newly described complication of COVID-19 pneumonia. The objective of this case presentation is to highlight an important complication and to explore potential predisposing risk factors and possible underlying pathophysiology of this phenomenon. Case presentation We present two patients with COVID-19 pneumonia complicated by spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema without positive pressure ventilation. Both patients had multiple comorbidities, received a combination of antibiotics, steroids and supportive oxygen therapy, and underwent routine laboratory workup. Both patients then developed spontaneous pneumomediastinum and ultimately required intubation and mechanical ventilation, which proved to be challenging to manage. Conclusions Spontaneous pneumomediastinum is a serious complication of COVID-19 pneumonia, of which clinicians should be aware. Further studies are needed to determine risk factors and laboratory data predictive of development of spontaneous pneumomediastinum in COVID-19 pneumonia.

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A case of spontaneous pneumomediastinum in a patient with severe SARS-CoV-2 and a review of the literature

SAGE Open Medical Case Reports ◽

10.1177/2050313x211010021 ◽

2021 ◽

Vol 9 ◽

pp. 2050313X2110100

Author(s):

Duong T Hua ◽

Farah Shah ◽

Cherlyn Perez-Corral

Keyword(s):

Subcutaneous Emphysema ◽

Lung Diseases ◽

Illicit Drugs ◽

Positive Pressure Ventilation ◽

Rare Complication ◽

Positive Pressure ◽

Chest Imaging ◽

Shortness Of Breath ◽

Spontaneous Pneumomediastinum ◽

Hypoxic Respiratory Failure

Spontaneous pneumomediastinum is defined as having an etiology that is not related to surgery, trauma, or mechanical ventilation. Precipitating causes of spontaneous pneumomediastinum include coughing, exercise, vomiting, infection, underlying lung diseases such as asthma, and illicit drugs. Symptoms include chest pain, shortness of breath, and dysphagia. A 54-year-old man presented with 2 weeks of shortness of breath, cough, and fever. He was admitted for severe SARS-CoV-2 pneumonia and acute hypoxic respiratory failure requiring non-rebreather mask. Chest imaging on admission showed bilateral peripheral consolidations and pneumomediastinum with subcutaneous emphysema. No precipitating event was identified. He did not require initiation of positive pressure ventilation throughout his admission. On hospital day 7, chest imaging showed resolution of pneumomediastinum and subcutaneous emphysema, and he was successfully discharged on oxygen therapy. Spontaneous pneumomediastinum is a rare complication of severe acute respiratory syndrome coronavirus 2 infection. Spontaneous pneumomediastinum is typically benign and self-limiting, requiring only supportive treatment.

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Subcutaneous emphysema and pneumomediastinum in patients with COVID-19 disease; case series from a tertiary care hospital in Pakistan

Epidemiology and Infection ◽

10.1017/s095026882100011x ◽

2021 ◽

Vol 149 ◽

Author(s):

S. M. Sethi ◽

A. S. Ahmed ◽

S. Hanif ◽

M. Aqeel ◽

A. B. S. Zubairi

Keyword(s):

Hospital Stay ◽

Subcutaneous Emphysema ◽

Positive Pressure Ventilation ◽

Invasive Mechanical Ventilation ◽

Tertiary Care ◽

Case Series ◽

Positive Pressure ◽

Care Hospital ◽

Spontaneous Pneumomediastinum ◽

Disease Case

Abstract Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23–75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. Eight out of ten patients had spontaneous pneumomediastinum on their initial chest x-ray in the emergency department. The median duration of assisted ventilation before the development of SE was 5.5 days (interquartile range, 5–10 days). The highest positive end-expiratory pressure (PEEP) was 10 cmH2O for patients recieving invasive mechanical ventilation, while 8 cmH2O was the average PEEP in patients who had developed subcutaneous emphysema on non-invasive ventilation. All patients received corticosteroids while six also received tocilizumab, and seven received convalescent plasma therapy, respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8−25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to COVID-19 triggered by the use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and SE whenever present, is associated with poor outcome in critically ill COVID-19 ARDS patients.

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Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in critically ill COVID-19 patients: A systematic review

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.38.3.5529 ◽

2022 ◽

Vol 38 (3) ◽

Author(s):

Kavous Shahsavarinia ◽

Golnarz Rahvar ◽

Hassan Soleimanpour ◽

Mohammad Saadati ◽

Leila Vahedi ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Critically Ill ◽

Subcutaneous Emphysema ◽

Significant Relationship ◽

Third Party ◽

Cochrane Library ◽

Positive Pressure ◽

Spontaneous Pneumomediastinum ◽

The Mean

Objectives: COVID-19 patients develop Life-threatening complications like pneumomediastinum/pneumothorax and emphysema which might experience prolonged hospital stays and additional costs might be imposed on the patient and the health system. The clinical features and outcomes of mechanically ventilated patients with COVID-19 infection who develop a pneumothorax, pneumomediastinum and subcutaneous emphysema has not been rigorously described or compared to those who do not develop these complications. So a systematic review of studies conducted on this subject was carried out to better manage these complications by investigating the underlying factors in COVID-19 patients. Methods: The search was conducted between early January and late December 2020 in databases including PubMed, Scopus, ProQuest, Embase, Cochrane Library, and Web of Science, using the following keywords and their combinations: COVID-19 Complication, Pneumothorax, Pneumomediastinum, Pneumopericardium, and Subcutaneous Emphysema. The extracted studies were screened separately by two researchers based on the PRISMA statement. After eliminating the duplicate studies, the title, abstract, and full text of the remaining studies were reviewed. Disagreements in the screening and selection of the studies were resolved by consensus or through a third-party opinion. Results: A total of 793 articles were retrieved through the literature search, and 99 studies conducted on a total of 139 patients were finally included The patient mortality was found to have a significant relationship with positive pressure ventilation (P=0.0001). There was no significant relationship between the patients’ death and chest tube insertion (P=0.2) or between the interval of time from the onset of symptoms to the diagnosis of pneumothorax (P=0.7). The mean age was higher in the deceased cases, and the mean difference observed was statistically significant (P=0.001). Conclusion: With the expansion of our clinical understanding of COVID-19, recognition of the uncommon complications of COVID-19 especially pneumothorax is crucial. Although in our review we couldn’t find a causal relationship between COVID-19 and pneumothorax or association between pneumothorax and death, as it is limited by many variables such as included studies’ design, or incomplete outcome data especially more information about the associated risk factors, we recommend performing more well-designed studies to describe the pneumothoraxes› incidence, risk factors, and outcomes in COVID-19 patients. doi: https://doi.org/10.12669/pjms.38.3.5529 How to cite this:Shahsavarinia K, Rahvar G, Soleimanpour H, Saadati M, Vahedi L, Mahmoodpoor A. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in critically ill COVID-19 patients: A systematic review. Pak J Med Sci. 2022;38(3):---------. doi: https://doi.org/10.12669/pjms.38.3.5529 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review

BMJ Case Reports ◽

10.1136/bcr-2020-239489 ◽

2020 ◽

Vol 13 (12) ◽

pp. e239489

Author(s):

Tarig Sami Elhakim ◽

Haleem S Abdul ◽

Carlos Pelaez Romero ◽

Yoandy Rodriguez-Fuentes

Keyword(s):

Literature Review ◽

Subcutaneous Emphysema ◽

Positive Pressure Ventilation ◽

Stable Condition ◽

Positive Pressure ◽

Unusual Complication ◽

Pathophysiological Mechanism ◽

Air Leak ◽

Non Invasive ◽

Spontaneous Pneumomediastinum

Spontaneous pneumomediastinum (SPM) and pneumothorax (PNX) unrelated to positive pressure ventilation has been recently reported as an unusual complication in cases of severe COVID-19 pneumonia. The presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. We present a case of COVID-19 pneumonia complicated on day 13 post admission by SPM, PNX and subcutaneous emphysema in a patient with no identifiable risk factors for such complication. The patient received medical treatment for his COVID-19 infection without the use of an invasive or non-invasive ventilator. Moreover, he is a non-smoker with no lung comorbidities and never reported a cough. He was eventually discharged home in stable condition. A comprehensive literature review revealed 15 cases of SPM developing in patients with COVID-19 pneumonia.

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Spontaneous Pneumomediastinum, Pneumothorax, Pneumopericardium and Subcutaneous Emphysema—Not So Uncommon Complications in Patients with COVID-19 Pulmonary Infection—A Series of Cases

Journal of Clinical Medicine ◽

10.3390/jcm10071346 ◽

2021 ◽

Vol 10 (7) ◽

pp. 1346

Author(s):

Talida Georgiana Cut ◽

Cristina Tudoran ◽

Voichita Elena Lazureanu ◽

Adelina Raluca Marinescu ◽

Raluca Dumache ◽

...

Keyword(s):

Mechanical Ventilation ◽

Subcutaneous Emphysema ◽

Diffuse Alveolar Damage ◽

Demographic Data ◽

Pathophysiological Mechanism ◽

Spontaneous Pneumomediastinum ◽

Intensive Care Stay ◽

Laboratory Investigations ◽

Male Patients ◽

Pulmonary Pathology

(1) Background: Spontaneous pneumomediastinum (PM), pneumothorax (PT), and pneumopericardium (PP) were recently reported as rare complications in patients with severe COVID-19 pneumonia, and our study aims to follow the evolution of these involvements in 11 cases. The presumed pathophysiological mechanism is air leak due to extensive diffuse alveolar damage followed by alveolar rupture. (2) Methods: We followed the occurrence of PM, PN, PP, and subcutaneous emphysema (SE) in 1648 patients hospitalized during the second outbreak of COVID-19 (October 2020–January 2021) in the main hospital of infectious diseases of our county and recorded their demographic data, laboratory investigations and clinical evolution. (3) Results: Eleven patients (0.66%) developed PM, with eight of them having associated PT, one PP, and seven SE, in the absence of mechanical ventilation. Eight patients (72.72%) died and only three (27.27%) survived. All subjects were nonsmokers, without known pulmonary pathology or risk factors for such complications. (4) Conclusions: pneumomediastinum, pneumothorax, and pneumopericardium are not so uncommon complications of SARS-CoV2 pneumonia, being observed mostly in male patients with severe forms and associated with prolonged hospitalization and poor prognosis. In some cases, with mild forms and reduced pulmonary injury, the outcome is favorable, not requiring surgical procedures, mechanical ventilation, or intensive care stay.

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Comparative study between noninvasive positive pressure ventilation and invasive mechanical ventilation in patients with respiratory failure

QJM ◽

10.1093/qjmed/hcab086.039 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Mohammed N Al Shafi'i ◽

Doaa M. Kamal El-din ◽

Mohammed A. Abdulnaiem Ismaiel ◽

Hesham M Abotiba

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Respiratory Failure ◽

Acute Respiratory Failure ◽

Positive Pressure Ventilation ◽

Invasive Mechanical Ventilation ◽

Noninvasive Positive Pressure Ventilation ◽

Positive Pressure ◽

Significant Difference

Abstract Background Noninvasive positive pressure ventilation (NIPPV) has been increasingly used in the management of respiratory failure in intensive care unit (ICU). Aim of the Work is to compare the efficacy and resource consumption of NIPPMV delivered through face mask against invasive mechanical ventilation (IMV) delivered by endotracheal tube in the management of patients with acute respiratory failure (ARF). Patients and Methods This prospective randomized controlled study included 78 adults with acute respiratory failure who were admitted to the intensive care unit. The enrolled patients were randomly allocated to receive either noninvasive ventilation or conventional mechanical ventilation (CMV). Results Severity of illness, measured by the simplified acute physiologic score 3 (SAPS 3), were comparable between the two patient groups with no significant difference between them. Both study groups showed a comparable steady improvement in PaO2:FiO2 values, indicating that NIPPV is as effective as CMV in improving the oxygenation of patients with ARF. The PaCO2 and pH values gradually improved in both groups during the 48 hours of ventilation. 12 hours after ventilation, NIPPMV group showed significantly more improvement in PaCO2 and pH than the CMV group. The respiratory acidosis was corrected in the NIPPV group after 24 hours of ventilation compared with 36 hours in the CMV group. NIPPV in this study was associated with a lower frequency of complications than CMV, including ventilator acquired pneumonia (VAP), sepsis, renal failure, pulmonary embolism, and pancreatitis. However, only VAP showed a statistically significant difference. Patients who underwent NIPPV in this study had lower mortality, and lower ventilation time and length of ICU stay, compared with patients on CMV. Intubation was required for less than a third of patients who initially underwent NIV. Conclusion Based on our study findings, NIPPV appears to be a potentially effective and safe therapeutic modality for managing patients with ARF.

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Management of an unusual presentation of foreign body aspiration

The Journal of Laryngology & Otology ◽

10.1017/s0022215100120791 ◽

1992 ◽

Vol 106 (8) ◽

pp. 751-752 ◽

Cited By ~ 11

Author(s):

Hassan H. Ramadan ◽

Nicolas Bu-Saba ◽

Anis Baraka ◽

Salman Mroueh

Keyword(s):

Foreign Body ◽

Subcutaneous Emphysema ◽

Positive Pressure Ventilation ◽

Intermittent Positive Pressure Ventilation ◽

Foreign Body Aspiration ◽

Positive Pressure ◽

Review Of The Literature ◽

X Ray ◽

Post Surgery ◽

Chest X Ray

AbstractForeign body aspiration is a very common problem in children and toddlers and still a serious and sometimes fatal condition. We are reporting on a 2-year-old white asthmatic male who choked on a chick pea and presented with subcutaneous emphysema, and on chest X-ray with an isolated pneumomediastinum but not pneumothorax. On review of the literature an isolated pneumomediastinum without pneumothorax was rarely reported. This presented a challenge in management mainly because of the technique that we had to use in order to undergo bronchoscopy and removal of the foreign body. Apnoeic diffusion oxygenation was used initially while the foreign body was removed piecemeal, and afterwards intermittent positive pressure ventilation was used. The child did very well, and his subcutaneous emphysema and pneumomediastinum remarkably improved immediately post surgery.

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Comparison of Early Nasal Intermittent Positive Pressure Ventilation and Nasal Continuous Positive Airway Pressure in Preterm Infants with Respiratory Distress Syndrome

Journal of Tropical Pediatrics ◽

10.1093/tropej/fmy058 ◽

2018 ◽

Vol 65 (4) ◽

pp. 352-360 ◽

Cited By ~ 2

Author(s):

Mesut Dursun ◽

Sinan Uslu ◽

Ali Bulbul ◽

Muhittin Celik ◽

Umut Zubarioglu ◽

...

Keyword(s):

Mechanical Ventilation ◽

Continuous Positive Airway Pressure ◽

Respiratory Distress Syndrome ◽

Airway Pressure ◽

Positive Pressure Ventilation ◽

Distress Syndrome ◽

Positive Airway Pressure ◽

Invasive Mechanical Ventilation ◽

Intermittent Positive Pressure Ventilation ◽

Positive Pressure

Abstract Aims To compare the effect of early nasal intermittent positive pressure ventilation (nIPPV) and nasal continuous positive airway pressure (nCPAP) in terms of the need for endotracheal ventilation in the treatment of respiratory distress syndrome (RDS) in preterm infants born between 24 and 32 gestational weeks. Methods This is a randomized, controlled, prospective, single-centered study. Forty-two infants were randomized to nIPPV and 42 comparable infants to nCPAP (birth weight 1356 ± 295 and 1359 ± 246 g and gestational age 29.2 ± 1.7 and 29.4 ± 1.5 weeks, respectively). Results The need for endotracheal intubation and invasive mechanical ventilation was significantly lower in the nIPPV group than the nCPAP group (11.9% and 40.5%, respectively, p < 0.05). There were no differences in the duration of total nasal respiratory support, duration of invasive mechanical ventilation, bronchopulmonary dysplasia or other early morbidities. Conclusion nIPPV compared with nCPAP reduced the need for endotracheal intubation and invasive mechanical ventilation in premature infants with RDS.

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