Abstract
Abstract Introduction Surgical emphysema is a relatively common occurrence in intensive care unit but its degree of spread in our patient is unusual. We present a case of a young adult with rapid widespread crepitus and worsening respiratory dynamics. Case description 35-year-old male with hypertension, type 2 diabetes and obesity was invasively ventilated for severe COVID-19 pneumonia. He developed reduced chest compliance, required high driving pressures, and had persistent hypoxia despite a high fraction of inspired oxygen. He was ventilated using protocolised ARDSNet lung protective ventilation (LPV) including periods of ventilation in the prone position. After 19 days of ventilation, worsening surgical emphysema was noted following a tracheostomy. Chest radiography demonstrated extensive extra-pulmonary air. Subsequent computed tomography confirmed widespread surgical emphysema from the face to the scrotum, bilateral pneumothoraces and pneumoperitoneum. Bilateral intercostal drains were inserted and LPV was continued. The pneumoperitoneum resolved with conservative management. The patient was mechanically ventilated for 59 days and was discharged home on day 104. Discussion Pneumothorax, pneumomediastinum and surgical emphysema can occur following high-pressure ventilation and surgical tracheostomy. However, pneumoperitoneum with extra-alveolar air collections communicating via potential fascial planes, perivascular sheaths or trans-diaphragmatic extension is rare. The cytokine storm postulated to occur in COVID-19 infection may cause alveolar destruction, leading to Macklin's phenomenon whereby air tracks along peri-bronchial vascular sheaths towards the mediastinum following alveolar rupture. In this patient, prolonged ventilation and high airway pressures probably compounded this effect and led to the complications described.
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