Massive Spontaneous Subcutaneous Emphysema and Pneumomediastinum as Rare Complications of COVID-19 Pneumonia

Combined Effects of Prone Positioning and Airway Pressure Release Ventilation on Oxygenation in Patients with COVID-19 ARDS

Objective

Coronavirus disease 2019 (COVID-19) can cause acute respiratory distress syndrome (ARDS). Invasive mechanical ventilation (IMV) support and prone positioning are essential treatments for severe COVID-19 ARDS. We aimed to determine the combined effect of prone position and airway pressure release ventilation (APRV) modes on oxygen improvement in mechanically-ventilated patients with COVID-19.

Methods

This prospective observational study included 40 eligible patients (13 female, 27 male). Of 40 patients, 23 (57.5%) were ventilated with APRV and 17 (42.5%) were ventilated with controlled modes. A prone position was applied when the PaO₂/FiO₂ ratio <150 mmHg despite IMV in COVID-19 ARDS. The numbers of patients who completed the first, second, and third prone were 40, 25, and 15, respectively. Incident barotrauma events were diagnosed by both clinical findings and radiological images.

Results

After the second prone, the PaO₂/FiO₂ ratio of the APRV group was higher compared to the PaO₂/FiO₂ ratio of the control group [189 (150-237)] vs. 127 (100-146) mmHg, respectively, (P=0.025). Similarly, after the third prone, the PaO₂/FiO₂ ratio of the APRV group was higher compared to the PaO₂/FiO₂ ratio of the control group [194 (132-263)] vs. 83 (71-136) mmHg, respectively, (P=0.021). Barotrauma events were detected in 13.0% of the patients in the APRV group and 11.8% of the patients in the control group (P=1000). The 28-day mortality was not different in the APRV group than in the control group (73.9% vs. 70.6%, respectively, P=1000).

Conclusion

Using the APRV mode during prone positioning improves oxygenation, especially in the second and third prone positions, without increasing the risk of barotrauma. However, no benefit on mortality was detected.

Extracorporeal membrane oxygenation rescue for severe pneumocystis pneumonia with the Macklin effect: a case report

Background

Pneumocystis jirovecii pneumonia (PJP) in an immunocompromised host is often associated with the Macklin effect, which can progress to spontaneous pneumomediastinum (SPM), subcutaneous emphysema (SCE), and pneumothorax (PNX). Diagnosing the causative organism of these conditions in non-HIV infected patients and treating hypoxemia while preventing further lung damage can be challenging. This study examines the case of a non-HIV infected male with SPM, SCE, and PNX secondary to severe Pneumocystis jirovecii (PJ) infection.

Case presentation

A 53-year-old male with pure red cell aplasia (PRCA) was admitted with fever, dry cough, and shortness of breath. His respiratory function progressively deteriorated due to the development of SPM, SCE, and PNX, eventually requiring endotracheal intubation and invasive ventilation. As a result of high pressure in his airways occasioned by lung recruitment maneuvers, his pulmonary parameters worsened, necessitating veno-venous (VV) extracorporeal membrane oxygenation (ECMO) therapy. The early initiation of VV-ECMO facilitated ultra-protective lung ventilation and prevented the progression of SPM, SCE, and PNX. Traditional diagnostic assays were unrevealing, whereupon the patient resorted to the metagenomic next-generation sequencing technology for uncovering potential pathogens. Consequently, we detected a significantly higher infection by PJ in the patient’s bronchoscopy lavage fluid. Finally, the patient was successfully treated with appropriate antimicrobials and was decannulated after nine days of ECMO support.

Conclusions

SPM, SCE, and PNX are rare clinical manifestations of PJP. However, they can be considered as poor prognostic factors of the infection. Physicians should, therefore, be alert to the possibility of PJP in immunocompromised patients.

An isolated spontaneous pneumomediastinum as a rare complication of COVID 19

The Coronavirus Disease 2019 (COVID-19) pandemic has displayed heterogeneity in disease manifestations and complications. This case report illustrates a rare issue : the spontaneous pneumomediastinum. A 73-year-old male presented with chills, and respiratory symptoms. A reverse transcriptase polymerase chain reaction (RT-PCR) test- confirmed COVID19. At admission, the patient was in severe respiratory distress. C reactive protein was 54 mg/l (normal: 0-5 mg/l), , troponin were negative, brain natriuretic peptid 55 pg/ml (normal range <100 pg/ml) and D-dimer 700 mcg/l (normal: 0-500 mcg/l). Arterial blood gases showed pH 7.49 (normal: 7.35-7.45), PCO2 33,8 mmHg (normal: 34-46 mmHg) and PO2 56 mmHg (normal: 80-97 mmHg) with 16 liter per minute of oxygen. Computed tomography of the chest (CT chest) showed diffuse groundglass opacities (60-70%) without pulmonary embolism. Diagnosis of acute respiratory distress syndrome (ARDS) was made. Low flow oxygen was provided (Oxygen saturation target ≥ 94%), intermediate dose of low molecular weight heparin and 8mg of dexamethason were administarted daily. On day 10, worsening hemodynamics and blood oxygen levels was noted. CT chest showed moderate bilateral pneumomediastinum, without pneumothorax, persistent groundglass opacities (75%) with early fibrosis elements. The patient recovered with no pulmonary sequelae. This case report encourages health workers to get used with infrequent clinical and radiological manifestations of COVID-19 that is still surprising the world.