PNEUMOMEDIASTINUM AND PNEUMOTHORAX DUE TO NONINVASIVE POSITIVE PRESSURE VENTILATION IN COVID-19 PNEUMONIA

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Barotrauma as a consequence of high alveolar pressures is well described in invasive mechanically ventilated (IMV) patients with pneumonia or pneumonitis. Limited data exists on the incidence of barotrauma in patients with Coronavirus Disease 19 pneumonia (COVID-19). We present a case of barotrauma occurring in a non-intubated patient with COVID-19 receiving noninvasive positive pressure ventilation (NPPV). CASE PRESENTATION: A 43-year-old male with obesity presented with 2 days of cough and dyspnea. Polymerase chain reaction (PCR) testing confirmed COVID-19. He initially required 5L of oxygen (O2) per minute by nasal cannula. Due to worsening hypoxemic respiratory failure (HRF) on day 3, the patient was placed on high-flow nasal cannula (HFNC) at 90% FiO2 at a flow rate of 30 L/min . By day 7, the patient had worsening HRF and increased work of breathing. He was transitioned to continuous positive airway pressure (CPAP) at 100% FiO2 with continuous pressure set at 12 cm H2O. On day 13, he developed tachycardia and desaturation. Chest CT found gas dissecting along the axial interstitium resulting in pneumomediastinum, bilateral pneumothoraces, and extensive subcutaneous emphysema. The lung parenchyma exhibited coarse ground glass opacities and early evidence of fibrotic changes. Chest tubes were placed in each hemithorax with resolution of his pnemothoraces after 5 days. His O2 requirements decreased, and he was transferred to a rehabilitation hospital on 10 L/min O2 by facemask on day 25. DISCUSSION: Barotrauma leading to pneumomediastinum and pneumothoraces are a well-documented complication of mechanical ventilation.1 In an effort to mitigate the morbidity and mortality associated with mechanical ventilation, many clinicians have shifted toward using NPPV in HRF in COVID-19, however NPPV may not necessarily protect patients against a complication more commonly associated with IMV.2,3 Progressive and cumulative alveolar injury may predispose COVID-19 patients to barotrauma regardless of mode of ventilation.3 CONCLUSIONS: Due to the mortality associated with IMV in COVID-19, many clinicians have shifted toward using NPPV to manage HRF. However, patients receiving NPPV may still be subject to complications such as barotrauma. Additionally, given our evolving understanding of COVID-19 and the pulmonary parenchymal distortion seen in many patients, a deterioration in respiratory status should prompt clinicians to search for evidence of barotrauma, even in patients receiving NPPV. Reference #1: Mentzer SJ, Tsuda A, Loring SH. Pleural mechanics and the pathophysiology of air leaks. J Thorac Cardiovasc Surg. 2018;155(5):2182-2189. Reference #2: Xu XP, Zhang XC, Hu SL, et al. Noninvasive Ventilation in Acute Hypoxemic Nonhypercapnic Respiratory Failure: A Systematic Review and Meta-Analysis. Crit Care Med. 2017;45(7):e727-e733. Reference #3: Sun R, Liu H, Wang X. Mediastinal Emphysema, Giant Bulla, and Pneumothorax Developed during the Course of COVID-19 Pneumonia. Korean J Radiol. 2020;21(5):541-544. DISCLOSURES: no disclosure on file for Nikhil Barot; No relevant relationships by Michael Kahn, source=Web Response No relevant relationships by Nader Kamangar, source=Web Response No relevant relationships by Jay Thetford, source=Web Response