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

Background In mechanically ventilated Acute Respiratory Distress Syndrome (ARDS) patients with novel coronavirus disease (COVID-19), we frequently recognised the development of pneumomediastinum and/or subcutaneous emphysema despite employing a protective mechanical ventilation strategy. The purpose of this study was to determine if the incidence of pneumomediastinum/subcutaneous emphysema in COVID-19 patients was higher than in ARDS patients without COVID-19 and if this difference could be attributed to barotrauma or to lung frailty.

Methods We identified the cohort of patients with ARDS and COVID-19 (“CoV-ARDS”), and the cohort of patients with ARDS from other causes (“noCoV-ARDS”).

Patients with CoV-ARDS were admitted to ICU during the COVID-19 pandemic and had microbiologically confirmed SARS-CoV-2 infection. NoCoV-ARDS was identified by an ARDS diagnosis in the 5 years before the COVID-19 pandemic period.

Results Pneumomediastinum/subcutaneous emphysema occurred in 23 out of 169 (13.6%) patients with CoV-ARDS and in 3 out of 163 (1.9%) patients with noCoV-ARDS (p<0.001). Mortality was 56.5% in CoV-ARDS patients with pneumomediastinum/subcutaneous emphysema and 50% in patients without pneumomediastinum (p=0.46).

CoV-ARDS patients had a high incidence of pneumomediastinum/subcutaneous emphysema despite the use of low tidal volume (5.9∓0.8 mL·kg⁻¹ ideal body weight) and low airway pressure (plateau pressure 23∓4 cmH₂O).

Conclusions We observed a seven-fold increase in pneumomediastinum/subcutaneous emphysema in CoV-ARDS. An increased lung frailty in CoV-ARDS could explain this finding more than barotrauma, which, according to its etymology, refers to high transpulmonary pressure.