PT  - JOURNAL ARTICLE
AU  - Daniel H.L. Lemmers
AU  - Mohammed Abu Hilal
AU  - Claudio Bnà
AU  - Chiara Prezioso
AU  - Erika Cavallo
AU  - Niccolò Nencini
AU  - Serena Crisci
AU  - Federica Fusina
AU  - Giuseppe Natalini
TI  - Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?
AID  - 10.1183/23120541.00385-2020
DP  - 2020 Oct 01
TA  - ERJ Open Research
PG  - 00385-2020
VI  - 6
IP  - 4
4099  - http://openres.ersjournals.com/content/6/4/00385-2020.short
4100  - http://openres.ersjournals.com/content/6/4/00385-2020.full
SO  - erjor2020 Oct 01; 6
AB  - Background In mechanically ventilated acute respiratory distress syndrome (ARDS) patients infected with the 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 both a cohort of patients with ARDS and COVID-19 (CoV-ARDS), and a cohort of patients with ARDS from other causes (noCoV-ARDS).Patients with CoV-ARDS were admitted to an intensive care unit (ICU) during the COVID-19 pandemic and had microbiologically confirmed severe acute respiratory syndrome coronavirus 2 (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 three 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.Pneumomediastinum is more frequent in #COVID19 patients with ARDS despite the use of a protective ventilatory approach. Lung frailty, and not barotrauma, appears to be the main cause of this finding. https://bit.ly/36FQe03