Pneumothorax and/or Pneumomediastinum Worsens the Prognosis of COVID-19 Patients with Severe Acute Respiratory Failure: A Multicenter Retrospective Case-Control Study in the North-East of Italy

Pneumomediastinum and pneumothorax in acute respiratory distress syndrome (ARDS) patients: a narrative review

Background and Objective

Acute respiratory distress syndrome (ARDS) is a severe, life-threatening medical condition characterized by poor oxygenation due to non-compliant lungs secondary diffuse alveolar damage. Encouragingly, the incidence of ARDS has declined steadily recently, attributed mainly to implementation of keystone guidelines and continuous research efforts. Mechanical ventilation is the cornerstone of supportive care for ARDS patients. This review aims to consolidate the current knowledge on pneumothorax (PNX) and pneumomediastinum (PMD) and to enhance the understanding of the readers. The objectives are to (I) explore the etiology and risk factors of PNX and PMD, (II) discuss the various diagnostic modalities available, (III) evaluate management options, and (IV) recent advancements.

Methods

A search of the literature was conducted using PubMed, MEDLINE, and Google Scholar for relevant articles pertaining to PNX and PMD in ARDS population. The clinical presentation, diagnostic and management strategies of PNX, PMD, and ARDS were summarized, and all authors reviewed the selection and decide which studies to include.

Key Content and Findings

The adoption of lung-protective ventilation strategies, based on the review of literature from the recent years, shows that it has played a significant role in reducing the occurrence of barotrauma, such as PNX and PMD. However, PNX and PMD remains to be a challenging complication to manage. With a specific focus on PNX and PMD, this review provides valuable insights into effectively managing and understanding these critical complications among ARDS patients.

Conclusions

ARDS, with its evolving definition, continues to pose a life-threatening threat. Despite the widespread adoption of lung-protective ventilation strategies, PNX and PMD present persistent challenges in management. Further research is imperative to enhance the risk assessment of ARDS patients prone to developing PNX and PMD and to institute more effective prevention and treatment measures.

Determinants of Pneumothorax Among Mechanically Ventilated COVID-19 Intensive Care Unit Patients, a Single Centre Study

Introduction

Millions of deaths and co-morbidities have been brought on by the COVID-19 epidemic worldwide. Acute respiratory distress syndrome (ARDS), multiple organ failure, and death can result from the condition in some people. The disease's course can range from a moderate upper respiratory tract infection to severe pneumonia. Numerous reports have been made on the occurrence of pneumothorax in COVID-19 ICU patients, particularly in those who are receiving invasive ventilation. This study assesses factors associated with pneumothorax among mechanically ventilated COVID-19 ICU patients in Addis Ababa, Ethiopia.

Methods

A case-control study design was employed from August 1, 2022, to August 31, 2022, GC, with a sample size of 281, where cases are 94 and controls are 187. A pre-tested structured quantitative tool was used to collect data on ODK and export it to SPSS version 26 for analysis. Descriptive statistics were presented using text and tables. The association between variables was analyzed with binary logistic regression. A statistical significance was declared at a p-value of 0.05 with a 95% confidence interval. Assumptions like model fitness and multicollinearity were checked to be satisfied.

Results

A total of 281 (94 cases and 187 controls) patient charts were carefully reviewed. After adjustment for possible confounders in multivariate analysis, ARDS (AOR = 0.214, 95% CI (0.088, 0.519), P value =0.001) and invasive ventilation (AOR = 0.311, 95% CI (0.121, 0.796), P value =0.015) had a significant association with pneumothorax.

Conclusion

Despite the introduction of preventive breathing methods, pneumothorax is still a frequent and deadly consequence in COVID-19 patients with ARDS. ARDS and invasive mechanical ventilation were found to be significantly associated with the development of pneumothorax. Health facilities should be well equipped with recent medical equipment in intensive care units and with well-trained and organized manpower.

Effects of pulmonary air leak on patients with coronavirus disease 2019 (COVID-19): a systematic review and meta-analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19) has posed increasing challenges to global health systems. We aimed to understand the effects of pulmonary air leak (PAL), including pneumothorax, pneumomediastinum and subcutaneous emphysema, on patients with COVID-19.

METHODS

We searched PubMed, Embase and Web of Science for data and performed a meta-analysis with a random-effects model using Stata 14.0. This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Thirty-five articles were included in the meta-analysis. The data came from 14 countries and included 3,047 COVID-19 patients with PAL, 11,3679 COVID-19 patients without PAL and 361 non-COVID-19 patients with PAL. We found that the incidence of PAL was much higher in COVID-19 patients than in non-COVID-19 patients (odds ratio (OR) = 6.13, 95% CI: 2.09-18.00). We found that the group of COVID-19 patients with PAL had a longer hospital stay (standardized mean difference (SMD) = 0.79, 95% CI: 0.27-1.30) and intensive care unit (ICU) stay (SMD = 0.51, 95% CI: 0.19-0.83) and comprised more ICU (OR = 15.16, 95% CI: 6.51-35.29) and mechanical ventilation patients (OR = 5.52, 95% CI: 1.69-17.99); furthermore, the mortality rate was also higher (OR = 2.62, 95% CI: 1.80-3.82).

CONCLUSIONS

Patients with lung injuries caused by COVID-19 may develop PAL. COVID-19 patients with PAL require more medical resources, have more serious conditions and have worse clinical outcomes.

PROSPERO REGISTRATION NUMBER

CRD42022365047.

Pleural Disease in Acute COVID-19 Pneumonia: A Single Center Retrospective Cohort Study

BACKGROUND

Pleural diseases encompass pleural effusion and pneumothorax (PTX), both of which were uncommon in coronavirus disease of 2019 (COVID-19). We aimed to describe the frequency, characteristics, and main outcomes of these conditions in patients with COVID-19 pneumonia.

METHODS

We performed a retrospective cohort analysis of inpatients with COVID-19 pneumonia between January 1, 2020 and January 1, 2022, at Beth Israel Deaconess Medical Center in Boston, Massachusetts.

RESULTS

Among 4419 inpatients with COVID-19 pneumonia, 109 (2.5%) had concurrent pleural disease. Ninety-four (2.1%) had pleural effusion (50% seen on admission) and 15 (0.3%) had PTX, both with higher rates of underlying conditions such as heart failure, liver disease, kidney disease, and malignancy. A total of 28 (30%) pleural effusions were drained resulting in 32% being exudative, 43% pseudoexudative, and 25% transudative. Regarding PTX, 5 (33%) were spontaneous and 10 (67%) were due to barotrauma while on mechanical ventilation. We found that the presence of underlying lung disease was not associated with an increased risk of developing PTX. In addition, patients with pleural disease had a higher incidence of severe or critical illness as represented by intensive care unit admission and intubation, longer hospital and intensive care unit stay, and a higher mortality rate as compared with patients without the pleural disease.

CONCLUSION

Pleural effusions and pneumothoraces are infrequent findings in patients admitted due to COVID-19 pneumonia, worsened outcomes in these patients likely reflect an interplay between the severity of inflammation and parenchymal injury due to COVID-19 disease and underlying comorbidities.

Barotrauma during Noninvasive Respiratory Support in COVID-19 Pneumonia Outside ICU: The Ancillary COVIMIX-2 Study

BACKGROUND

Noninvasive respiratory support (NIRS) has been extensively used during the COVID-19 surge for patients with acute respiratory failure. However, little data are available about barotrauma during NIRS in patients treated outside the intensive care unit (ICU) setting.

METHODS

COVIMIX-2 was an ancillary analysis of the previous COVIMIX study, a large multicenter observational work investigating the frequencies of barotrauma (i.e., pneumothorax and pneumomediastinum) in adult patients with COVID-19 interstitial pneumonia. Only patients treated with NIRS outside the ICU were considered. Baseline characteristics, clinical and radiological disease severity, type of ventilatory support used, blood tests and mortality were recorded.

RESULTS

In all, 179 patients were included, 60 of them with barotrauma. They were older and had lower BMI than controls (p < 0.001 and p = 0.045, respectively). Cases had higher respiratory rates and lower PaO₂/FiO₂ (p = 0.009 and p < 0.001). The frequency of barotrauma was 0.3% [0.1-1.3%], with older age being a risk factor for barotrauma (OR 1.06, p = 0.015). Alveolar-arterial gradient (A-a) DO₂ was protective against barotrauma (OR 0.92 [0.87-0.99], p = 0.026). Barotrauma required active treatment, with drainage, in only a minority of cases. The type of NIRS was not explicitly related to the development of barotrauma. Still, an escalation of respiratory support from conventional oxygen therapy, high flow nasal cannula to noninvasive respiratory mask was predictive for in-hospital death (OR 15.51, p = 0.001).

CONCLUSIONS

COVIMIX-2 showed a low frequency for barotrauma, around 0.3%. The type of NIRS used seems not to increase this risk. Patients with barotrauma were older, with more severe systemic disease, and showed increased mortality.

Pneumothorax in hospitalized COVID-19 patients with severe respiratory failure: Risk factors and outcome

PNX was described as an uncommon complication in COVID-19 patients but clinical risk predictors and the potential role in patient's outcome are still unclear. We assessed prevalence, risk predictors and mortality of PNX in hospitalized COVID- 19 with severe respiratory failure performing a retrospective observational analysis of 184 patients admitted to our COVID-19 Respiratory Unit in Vercelli from October 2020 to March 2021. We compared patients with and without PNX reporting prevalence, clinical and radiological features, comorbidities, and outcomes. Prevalence of PNX was 8.1% and mortality was >86% (13/15) significantly higher than in patients without PNX (56/169) (P < 0.001). PNX was more likely to occur in patients with a history of cognitive decline (HR: 31.18) who received non-invasive ventilation (NIV) (p < 0.0071) and with low P/F ratio (HR: 0.99, p = 0.004). Blood chemistry in the PNX subgroup compared to patients without PNX showed a significant increase in LDH (420 U/L vs 345 U/L, respectively p = 0.003), ferritin (1111 mg/dl vs 660 mg/dl, respectively p = 0.006) and decreased lymphocytes (HR: 4.440, p = 0.004). PNX may be associated with a worse prognosis in terms of mortality in COVID patients. Possible mechanisms may include the hyperinflammatory status associated with critical illness, the use of NIV, the severity of respiratory failure and cognitive impairment. We suggest, in selected patients showing low P/F ratio, cognitive impairment and metabolic cytokine storm, an early treatment of systemic inflammation in association with high-flow oxygen therapy as a safer alternative to NIV in order to avoid fatalities connected with PNX.

Spontaneous pneumomediastinum: a surrogate of P-SILI in critically ill COVID-19 patients

Spontaneous pneumomediastinum (SP) has been described early during the COVID-19 pandemic in large series of patients with severe pneumonia, but most patients were receiving invasive mechanical ventilation (IMV) at the time of SP diagnosis. In this retrospective multicenter observational study, we aimed at describing the prevalence and outcomes of SP during severe COVID-19 with pneumonia before any IMV, to rule out mechanisms induced by IMV in the development of pneumomediastinum.Among 549 patients, 21 patients (4%) developed a SP while receiving non-invasive respiratory support, after a median of 6 days [4-12] from ICU admission. The proportion of patients requiring IMV was similar. However, the time to tracheal intubation was longer in patients with SP (6 days [5-13] vs. 2 days [1-4]; P = 0.00002), with a higher first-line use of non-invasive ventilation (n = 11; 52% vs. n = 150; 28%; P = 0.02). The 21 patients who developed a SP had persisting signs of severe lung disease and respiratory failure with lower ROX index between ICU admission and occurrence of SP (3.94 [3.15-5.55] at admission vs. 3.25 [2.73-4.02] the day preceding SP; P = 0.1), which may underline potential indirect signals of Patient-self inflicted lung injury (P-SILI).In this series of critically ill COVID-19 patients, the prevalence of SP without IMV was not uncommon, affecting 4% of patients. They received more often vasopressors and had a longer ICU length of stay, as compared with their counterparts. One pathophysiological mechanism may potentially be carried out by P-SILI related to a prolonged respiratory failure, as underlined by a delayed use of IMV and the evolution of the ROX index between ICU admission and the day preceding SP.

Evaluation of the Prevalence of Barotrauma and Affecting Factors in Patients with COVID-19 during Follow-Up in the Intermediate Care Unit

It is known that pneumothorax (PX) and pneumomediastinum (PM) develop due to COVID-19 disease. The objective of our study was to determine the prevalence of PX/PM due to COVID-19 in the intermediate intensive care unit (IMCU) and to evaluate the factors causing barotrauma and also the clinical outcomes of these patients. A total of 283 non-intubated patients with COVID-19 pneumonia followed up in the IMCU in a 1-year period were included in the study. The patients were classified as group 1 (having barotrauma) and group 2 (without barotrauma). The rate of barotrauma was 8.1% (n = 23, group 1). PX developed on the right hemithorax in 12 (70.6%) patients. Group 1 had statistically significantly higher 28-day mortality rates compared with group 2 (p = 0.014). The eosinophil and d-dimer levels of the patients in group 1 were higher, while C-reactive protein (CRP), fibrinogen, and albumin levels were lower than Group 2 (p < 0.001, p = 0.017, p = 0.001, p < 0.001), and p < 0.001, respectively). The similar rates of NIMV administration in our study groups support that barotrauma is not the only mechanism in the development of PX/PM. The findings of high blood eosinophil count and low blood levels of CRP, albumin, and fibrinogen in the barotrauma group of our study might be a pathfinder for future studies.

Pulmonary Barotrauma in COVID-19 Patients: Experience From a Secondary Care Hospital in Oman

Background

During the COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), many patients developed pulmonary barotrauma either self-inflicted or ventilator-induced. In pulmonary barotrauma, air leaks into extra-alveolar tissue resulting in pneumomediastinum, subcutaneous emphysema, pneumothorax, and pneumoperitoneum.

Methods

After obtaining institutional approval, we retrospectively reviewed data from March 1, 2021, to September 31, 2021. Being a retrospective study, informed consent was not applicable. Patient data were collected from the Al Shifa patient information portal, which is an electronic medical record system available to all hospitals in the Ministry of Health, Oman. After identifying patients with pulmonary barotrauma, the following details were recorded and entered into an Excel sheet (Microsoft Corporation, Albuquerque, New Mexico) and a database was created, which contained the following: age, sex, smoking history, comorbidities, type, location, mode of barotrauma, mode of ventilation, length of intensive care unit (ICU) stay, interventions performed, and overall outcome (survived/deceased).

Results

A total of 529 patients with COVID-19 pneumonia were admitted from March 2021 to September 2021 to the ICU. Twenty-eight patients developed barotrauma of variable severity and required interventions like the placement of intercostal drains. Out of 28, five patients developed spontaneous barotrauma, 14 patients had barotrauma after initiation of non-invasive ventilation, and nine patients had barotrauma as a result of invasive ventilation. The median number of days in the ICU was 19.5 (interquartile range: 12.5-26.5). Of the 28 patients, eight patients survived and were discharged from the hospital.

Conclusion

In this single-center, retrospective study at a secondary care hospital in Oman, we described our experience with patients who suffered pulmonary barotrauma during their ICU admission. We have also presented the incidence of spontaneous versus ventilator-induced barotrauma, the length of stay of these patients, the outcomes in terms of survival or death, the need for tracheostomy, secondary infections, and interventions performed as indicated.

ST-Segment Elevation Secondary to Spontaneous Pneumomediastinum in the Setting of COVID-19 Infection: A Case Report and Literature Review

A 45-year-old male presented with shortness of breath, cough,and chest discomfort. He reported positive test results for coronavirus disease 2019 (COVID-19) four days prior; this was confirmed by a second test administered at the hospital. Results of a chest CT, consistent with COVID-19 pneumonia, also revealed pneumomediastinum (PM). EKG showed ST elevations in the inferior leads with no reciprocal changes. Emergent cardiac catheterization showed that he had no stenosis in his major coronary arteries. His symptoms resolved after 25 days of hospitalization and the patient was ultimately discharged. This case highlights the importance of recognizing spontaneous PM as a complication of COVID-19 along with its uncommon presentation of ST elevation in order to prevent unnecessary invasive procedures.

Risk Factors for Pulmonary Air Leak and Clinical Prognosis in Patients With COVID-19 Related Acute Respiratory Failure: A Retrospective Matched Control Study

Background

The role of excessive inspiratory effort in promoting alveolar and pleural rupture resulting in air leak (AL) in patients with SARS-CoV-2 induced acute respiratory failure (ARF) while on spontaneous breathing is undetermined.

Methods

Among all patients with COVID-19 related ARF admitted to a respiratory intensive care unit (RICU) and receiving non-invasive respiratory support, those developing an AL were and matched 1:1 [by means of PaO2/FiO2 ratio, age, body mass index-BMI and subsequent organ failure assessment (SOFA)] with a comparable population who did not (NAL group). Esophageal pressure (ΔP_es) and dynamic transpulmonary pressure (ΔP_L) swings were compared between groups. Risk factors affecting AL onset were evaluated. The composite outcome of ventilator-free-days (VFD) at day 28 (including ETI, mortality, tracheostomy) was compared between groups.

Results

Air leak and NAL groups (n = 28) showed similar ΔP_es, whereas AL had higher ΔP_L (20 [16–21] and 17 [11–20], p = 0.01, respectively). Higher ΔP_L (OR = 1.5 95%CI[1–1.8], p = 0.01), positive end-expiratory pressure (OR = 2.4 95%CI[1.2–5.9], p = 0.04) and pressure support (OR = 1.8 95%CI[1.1–3.5], p = 0.03), D-dimer on admission (OR = 2.1 95%CI[1.3–9.8], p = 0.03), and features suggestive of consolidation on computed tomography scan (OR = 3.8 95%CI[1.1–15], p = 0.04) were all significantly associated with AL. A lower VFD score resulted in a higher risk (HR = 3.7 95%CI [1.2–11.3], p = 0.01) in the AL group compared with NAL. RICU stay and 90-day mortality were also higher in the AL group compared with NAL.

Conclusion

In spontaneously breathing patients with COVID-19 related ARF, higher levels of ΔP_L, blood D-dimer, NIV delivery pressures and a consolidative lung pattern were associated with AL onset.

An Imaging Overview of COVID-19 ARDS in ICU Patients and Its Complications: A Pictorial Review

A significant proportion of patients with COVID-19 pneumonia could develop acute respiratory distress syndrome (ARDS), thus requiring mechanical ventilation, and resulting in a high rate of intensive care unit (ICU) admission. Several complications can arise during an ICU stay, from both COVID-19 infection and the respiratory supporting system, including barotraumas (pneumothorax and pneumomediastinum), superimposed pneumonia, coagulation disorders (pulmonary embolism, venous thromboembolism, hemorrhages and acute ischemic stroke), abdominal involvement (acute mesenteric ischemia, pancreatitis and acute kidney injury) and sarcopenia. Imaging plays a pivotal role in the detection and monitoring of ICU complications and is expanding even to prognosis prediction. The present pictorial review describes the clinicopathological and radiological findings of COVID-19 ARDS in ICU patients and discusses the imaging features of complications related to invasive ventilation support, as well as those of COVID-19 itself in this particularly fragile population. Radiologists need to be familiar with COVID-19's possible extra-pulmonary complications and, through reliable and constant monitoring, guide therapeutic decisions. Moreover, as more research is pursued and the pathophysiology of COVID-19 is increasingly understood, the role of imaging must evolve accordingly, expanding from the diagnosis and subsequent management of patients to prognosis prediction.