key: cord-0692017-93q1onan
authors: Martelli, Gabriele; Tiberio, Ivo
title: Pneumothorax and pulmonary air leaks as ventilator-induced injuries in COVID-19
date: 2021-01-13
journal: Acute Crit Care
DOI: 10.4266/acc.2020.00955
sha: 8472d9694e2ef156b6ff8dd985dcdc0dca759a1b
doc_id: 692017
cord_uid: 93q1onan

nan

. Chest X-ray (A) and computed tomography thoracic scan (B) of a 59-year-old male coronavirus disease 2019 (COVID-19) patient after 3 days of invasive ventilation. Ventilation occurred in pressure-control mode with the following parameters: peak inspiratory pressure, 27 cm H2O; positive end-expiratory pressure, 12 cm H2O; fraction of inspired oxygen, 0.6; inspiratory to expiratory ratio, 1:2; and respiratory rate, 16. The last measurement prior to the occurrence of pneumothorax was a plateau pressure of 25 cm H2O and static compliance of 43 L/cm H2O. Bilateral inhomogeneous parenchyma and consolidative aspects of the left lung were noted. The patient developed left pneumothorax and pneumomediastinum. On chest X-ray, subcutaneous emphysema is evident.

Pneumothorax and other manifestations of pulmonary air leak (pneumomediastinum, subcutaneous emphysema) are well-known complications of coronavirus disease 2019 (COV-ID-19). The overall incidence of these complications in COVID-19 patients has been estimated to be 1% [1] . However, in mechanically ventilated COVID-19 patients, the incidence of pneumothorax and air leaks rises to 15% [2] . Despite the widespread use of protective ventilation techniques these complications remain a major concern. Severe cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia present with acute alterations such as pulmonary edema and diffuse alveolar damage [3] , with a classical acute respiratory distress syndrome pattern. As a result of acute-phase alterations, there may be a negative evolution towards parenchymal consolidations and fibrosis. Due to these processes, COV-ID-19 patients could present with inhomogeneous pulmonary parenchyma and reduced compliance. Inhomogeneous parenchyma facilitates acute air leaks through the maldistribution of ventilatory stress (Figure 1 ty develop different local stresses [4] . Reduced compliance promotes lung injury and also tends to hinder re-expansion of the lungs after air drainage (Figure 2 ). These factors are also involved in self-inflicted lung injury [5] and could explain the growing number of cases of pneumothorax and acute air leaks in COVID-19 patients undergoing noninvasive protective ventilation (Figure 3 ) .

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No potential conflict of interest relevant to this article was reported.