key: cord-0800872-d597hjwq
authors: Mart, Matthew F.; Norfolk, Stephanie G.; Flemmons, Lisa N.; Stokes, John W.; Bacchetta, Matthew D.; Trindade, Anil J.; Casey, Jonathan D.; Semler, Matthew W.; Ely, E. Wesley; Noto, Michael J.
title: Pneumomediastinum in Acute Respiratory Distress Syndrome from COVID-19
date: 2021-01-15
journal: Am J Respir Crit Care Med
DOI: 10.1164/rccm.202008-3376im
sha: a9556d09dfdc4d4b9515bbf3f7ca246ff3c98952
doc_id: 800872
cord_uid: d597hjwq

nan

Pneumomediastinum is an uncommon complication of acute respiratory distress syndrome (ARDS) from viral infections, including severe acute respiratory syndrome coronavirus 1 (1) . Barotrauma from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (i.e., coronavirus disease [COVID-19]) has been increasingly described (2, 3) .

We report five patients with pneumomediastinum of 92 critically ill, mechanically ventilated adults with ARDS from COVID-19 at our institution from March 1, 2020, through August 31, 2020 ( Figure 1 ). Unlike other reports (4, 5) , no patient had pneumothorax or required tube thoracostomy at diagnosis, suggesting alveolar rupture occurred without disruption of visceral pleura. Pneumomediastinum developed between 24 hours before and 9 days after initiation of mechanical ventilation without evidence of tracheal injury or the use of recruitment maneuvers. Patients received low-VT ventilation targeting plateau pressures ,30 cm H 2 O to minimize driving pressure, with sedation and/or paralysis used to reduce initial high respiratory effort and limit dyssynchrony. Our cumulative incidence (5.4%) of pneumomediastinum without pneumothorax falls between incidences reported in other series (2, 3). All patients later developed other barotrauma days after initial diagnosis, including two patients who developed pneumopericardium and one who developed pneumoperitoneum with severe subcutaneous emphysema from the neck to the pelvis (Figure 2 ). Four of the five patients died during hospitalization, with the remaining patient being discharged alive. n Author disclosures are available with the text of this article at www.atsjournals.org.

Spontaneous pneumomediastinum in patients with severe acute respiratory syndrome

High incidence of barotrauma in patients with COVID-19 infection on invasive mechanical ventilation

COVID-19 and pneumothorax: a multicentre retrospective case series

Pneumomediastinum following intubation in COVID-19 patients: a case series

Incidence of barotrauma in patients with COVID-19 pneumonia during prolonged invasive mechanical ventilation -a case-control study

Extensive bilateral ground glass opacification and consolidation is present, consistent with his known ARDS. Significant pneumomediastinum is demonstrated in addition to extensive subcutaneous emphysema across the chest, arms, and back