key: cord-0913990-rmssjhfg
authors: Thomas, Pravin; Wasef, Natale; Kaplan, Adam
title: A REPORT OF SECONDARY PNEUMOMEDIASTINUM DUE TO CPAP NONINVASIVE VENTILATION IN COVID-19 TREATMENT
date: 2021-10-31
journal: Chest
DOI: 10.1016/j.chest.2021.07.1185
sha: fcff91d47a85f938b5ac99d9df57301bcf32912e
doc_id: 913990
cord_uid: rmssjhfg

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CASE PRESENTATION: Our patient was an 86-year-old female with a past medical history significant for diabetes, hypertension and seizures who presented to our institution with one week of abdominal pain, watery diarrhea, nausea, vomiting and a cough. She was initially hypoxic on presentation and required a non-rebreather mask for oxygen support. She tested positive for COVID 19 on a nasopharyngeal swab. On admission, her chest x-ray (CXR) showed bilateral lung infiltrates. A computerized tomography scan (CT) of the abdomen and pelvis showed scattered ground-glass airspace disease within the lower lungs bilaterally. She was started on Dexamethasone, Remdesivir, Ceftriaxone and Doxycycline. During hospitalization, the patient's oxygen requirements increased to high flow oxygen support and then to CPAP with a positive end expiratory pressure (PEEP) of 10 and Fraction of Inspired oxygen of 100%. On day 5, the patient had an oxygen saturation of 73%. Emergent CXR uncovered new extensive subcutaneous emphysema and findings suspicious for a PNM with unchanged bilateral airspace consolidation. The patient was intubated, mechanically ventilated on PRVC (Pressure Regulated Volume Control) settings and upgraded to the Intensive Care Unit (ICU). Serial CXRs were performed thereafter which demonstrated improvement and resolution of the subcutaneous emphysema. However, the patient continued to deteriorate clinically, and was eventually terminally extubated and passed away.

DISCUSSION: Pneumomediastinum cases have been reported across all points in the time-course of COVID presentation in a recent literature review by Quincho et al. PNMs have been reported in COVID 19 patients without any NIVV, while on NIVV and also during invasive mechanical ventilation.Spontaneous PNMs are thought to be due to the "Macklin" effect, wherein alveolar rupture leads to air movement along bronchovascular sheaths into the mediastinum. In the context of COVID-19 associated PNMs where no positive pressure ventilation was used, Elkahim et al. have postulated diffuse alveolar injury with rupture and air leak as a possible mechanism. In our case, the addition of CPAP may have induced barotrauma and alveolar air leak, particularly in the setting of pre-existing COVID-19 alveolar lung injury.

Our case adds to the growing literature on pneumomediastinums and air leaks among COVID 19 patients. We suspect that patients with COVID-19 are at increased risk of pneumomediastinum independent or barotrauma, and that the combination of NIVV may have a synergistic effect of increased risk of pneumomediastinum.

Case Report: Pneumothorax and Pneumomediastinum as Uncommon Complications of COVID-19 Pneumonia-Literature Review

Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: interpretation of the clinical literature in the light of laboratory experiment

DISCLOSURES: No relevant relationships by Adam Kaplan, source¼Web Response No relevant relationships by Pravin Thomas, source¼Web Response No relevant relationships by Natale Wasef

American College of Chest Physicians