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Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?

Daniel H.L. Lemmers, Mohammed Abu Hilal, Claudio Bnà, Chiara Prezioso, Erika Cavallo, Niccolò Nencini, Serena Crisci, Federica Fusina, Giuseppe Natalini
ERJ Open Research 2020 6: 00385-2020; DOI: 10.1183/23120541.00385-2020
Daniel H.L. Lemmers
1Dept of Surgery, Fondazione Poliambulanza, Brescia, Italy
2Dept of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
6These authors contributed equally
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  • ORCID record for Daniel H.L. Lemmers
Mohammed Abu Hilal
1Dept of Surgery, Fondazione Poliambulanza, Brescia, Italy
6These authors contributed equally
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Claudio Bnà
3Dept of Radiology, Fondazione Poliambulanza, Brescia, Italy
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Chiara Prezioso
4Dept of Anesthesia and Intensive Care, Fondazione Poliambulanza, Brescia, Italy
5Dept of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
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Erika Cavallo
4Dept of Anesthesia and Intensive Care, Fondazione Poliambulanza, Brescia, Italy
5Dept of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
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Niccolò Nencini
4Dept of Anesthesia and Intensive Care, Fondazione Poliambulanza, Brescia, Italy
5Dept of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
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Serena Crisci
4Dept of Anesthesia and Intensive Care, Fondazione Poliambulanza, Brescia, Italy
5Dept of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
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Federica Fusina
4Dept of Anesthesia and Intensive Care, Fondazione Poliambulanza, Brescia, Italy
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  • ORCID record for Federica Fusina
Giuseppe Natalini
4Dept of Anesthesia and Intensive Care, Fondazione Poliambulanza, Brescia, Italy
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  • For correspondence: giuseppe.natalini@poliambulanza.it
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    FIGURE 1

    Chest computed tomography scan, performed in a patient with multiple ground-glass lesions and infiltrates (acute respiratory distress syndrome (ARDS) secondary to novel coronavirus disease 2019). The scan shows the Macklin effect due to alveolar rupture, air leakage and dissection along bronchovascular sheaths with pulmonary interstitial emphysema and pneumomediastinum, that extends widely along the muscle bundles of the chest and neck. A subcutaneous emphysema and extension of pneumomediastinum in the abdomen is also seen.

Tables

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  • TABLE 1

    Baseline characteristics on first day of mechanical ventilation and outcomes in patients with acute respiratory distress syndrome (ARDS) secondary to novel coronavirus disease (COVID-19) and ARDS from other diseases

    VariablesCoV-ARDSnoCoV-ARDSp-value
    Subjects n169163
    Age years66 (59–71)72 (62–78)<0.001
    Male sex133 (78.7)106 (65.4)0.007
    Body mass index kg·m−228 (25–31)27 (24–31)0.02
    Diabetes mellitus26 (15.4)47 (29)0.003
    Arterial hypertension90 (53.3)96 (59.3)0.27
    COPD4 (2.4)22 (13.5)<0.001
    Positive end-expiratory pressure cmH2O12 (10–14)8 (5–9)<0.001
    Peak airway pressure cmH2O30±522±6<0.001
    Plateau airway pressure cmH2O23±419±3<0.001
    pH7·29±0.127·33±0.140.15
    PaCO2 mmHg56±1646±12<0.001
    Compliance of the respiratory system mL·cmH2O−128 (22–34)35 (25–43)<0.001
    Minute ventilation L·min−18.8±1.38.7±2.30.62
    Corrected minute ventilation L·min−112.4 (9.3–15)9.6 (7.5–11.8)<0.001
    PaO2/FIO2 mmHg111 (86–153)140 (100–198)<0.001
    Tidal volume/ideal body weight mL·kg−15.9±0.86.6±1.3<0.001
    Length of stay in intensive care unit10 (5–18)7 (3–20)0.22
    Length of stay in hospital15 (9–24)20 (11–33)0.002
    In-hospital mortality86 (50.9)43 (26.6)<0.001
    Pneumomediastinum/subcutaneous emphysema23 (13.6)3 (1.9)<0.001

    Data are presented as median (interquartile range), n (%) or mean±sd, unless otherwise stated. CoV-ARDS: ARDS from COVID-19; noCoV-ARDS: ARDS secondary to other diseases; PaCO2: arterial carbon dioxide tension; PaO2: arterial oxygen tension; FIO2: inspiratory oxygen fraction.

    • TABLE 2

      Baseline characteristics and outcomes in patients with acute respiratory distress syndrome (ARDS) secondary to novel coronavirus disease (COVID-19) with and without pneumomediastinum/subcutaneous emphysema (P/SE)

      VariablesWithout P/SEWith P/SEp-value
      Subjects n14623
      Age years67 (59–71)64 (60–70)0.24
      Male sex118 (80.8)15 (65)0.09
      Body mass index kg·m−228 (26–31)27 (25–31)0.29
      Diabetes mellitus23 (15.8)3 (13)0.74
      Arterial hypertension79 (54.1)11 (47.8)0.58
      COPD4 (2.7)0 (0)1
      Positive end-expiratory pressure cmH2O12 (10–14)12 (8–15)0.72
      Peak airway pressure cmH2O29±530±50.56
      Plateau airway pressure cmH2O23±424±60.80
      pH7.28±0.127.33±0.110.07
      PaCO2 mmHg57±1653±150.26
      Compliance of the respiratory system mL·cmH2O−127 (22–33)28 (22–36)0.55
      Minute ventilation L·min−18.9±1.38.3±1.10.04
      Corrected minute ventilation L·min−112.7 (9.4–15)9.9 (8.4–13.1)0.07
      PaO2/FIO2 mmHg114 (86–153)105 (81–137)0.21
      Tidal volume/ideal body weight mL·kg−15.9±0.86.1±0.90.23
      Length of stay in intensive care unit9 (5–18)11 (6–21)0.44
      Length of stay in hospital14 (8–23)18 (12–28)0.18
      In-hospital mortality73 (50)13 (56.5)0.46

      Data are presented as median (interquartile range), n (%) or mean±sd, unless otherwise stated. PaCO2: arterial carbon dioxide tension; PaO2: arterial oxygen tension; FIO2: inspiratory oxygen fraction.

      • TABLE 3

        Ventilatory variables of patients with acute respiratory distress syndrome (ARDS) secondary to novel coronavirus disease (COVID-19) who developed pneumomediastinum/subcutaneous emphysema (n=23)

        VariablesOn the first day of mechanical ventilationOn the day of P/SEp-value
        Positive end-expiratory pressure cmH2O12 (8–15)9 (6–13)0.002
        Peak airway pressure cmH2O30±529±50.08
        Plateau airway pressure cmH2O24±522±40.045
        pH7.32±0.097.33±0.130.4
        PaCO2 mmHg54±1453±120.77
        Compliance of the respiratory system mL·cmH2O−125 (22–34)33 (27–40)0.13
        Minute ventilation L·min−18.4±1.28.9±2.10.13
        Corrected minute ventilation L·min−111.5±412.1±4.10.45
        PaO2/FIO2 mmHg108±33131±760.13
        Tidal volume/ideal body weight mL·kg−16±0.96.7±1.70.008

        Data are presented as median (interquartile range) or mean±sd, unless otherwise stated. P/SE: pneumomediastinum/subcutaneous emphysema; PaCO2: arterial carbon dioxide tension; PaO2: arterial oxygen tension; FIO2: inspiratory oxygen fraction.

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        Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?
        Daniel H.L. Lemmers, Mohammed Abu Hilal, Claudio Bnà, Chiara Prezioso, Erika Cavallo, Niccolò Nencini, Serena Crisci, Federica Fusina, Giuseppe Natalini
        ERJ Open Research Oct 2020, 6 (4) 00385-2020; DOI: 10.1183/23120541.00385-2020

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        Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?
        Daniel H.L. Lemmers, Mohammed Abu Hilal, Claudio Bnà, Chiara Prezioso, Erika Cavallo, Niccolò Nencini, Serena Crisci, Federica Fusina, Giuseppe Natalini
        ERJ Open Research Oct 2020, 6 (4) 00385-2020; DOI: 10.1183/23120541.00385-2020
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