Pneumomediastinum in COVID-19 critically ill patients: A case series of unusual complication from a Tunisian intensive care unit

Abstract

Introduction: Coronavirus disease 2019 (COVID-19) is a new rapidly emerging and ever-evolving disease that clinicians continue to detect new manifestations and complications daily since December 2019. Pneumomediastinum, a potentially life-threatening condition, is an uncommon complication of acute respiratory distress syndrome from viral infections. By presenting this case series, we highlight that pneumomediastinum (PM) can complicate the course of a severe COVID-19 infection. Case Series: We identified four critically ill patients, two men and two women, aged between 50 and 70 years old. None of them had any underlying lung disease. On admission all cases were in acute respiratory distress syndrome. Three patients were under positive pressure ventilation both invasive (n = 2/4) and non-invasive (n = 1/4) at the time of the event; however, one patient had a spontaneous PM without any exposure to mechanical ventilation. Chest computed tomography scan (chest CT scan) was performed for all patients showing a pulmonary involvement estimated moderate (n = 3/4) to severe (n = 1/4), PM (n = 4/4) and subcutaneous emphysema (n = 2/4). For ventilated patients, PM was diagnosed 3 to 7 days after initiation of mechanical ventilation. The highest positive end-expiratory pressure was 10 cmH2O for patients receiving invasive mechanical ventilation, while 5 cmH2O for patient who had developed PM on non-invasive ventilation. The PM was managed by conservative therapy in all of the cases with reducing airway pressure. Conclusion: Our findings suggest that PM is secondary to inflammatory response due to COVID-19 and mostly triggered by the use of positive pressure ventilation and it is associated with poor outcome in critically ill COVID-19 patients.