Case series
Patients: Male, 71-year-old • Female, 58-year-old
Final Diagnosis: Pulmonary barotrauma
Symptoms: Pneumomediastinum
Medication: —
Clinical Procedure: Chest tube
Specialty: Critical Care Medicine
Invasive mechanical ventilation can cause pulmonary barotrauma due to elevated transpulmonary pressure and alveolar rupture. A significant proportion of COVID-19 patients with acute respiratory distress syndrome (ARDS) will require mechanical ventilation. We present 2 interesting cases that demonstrate the possibility of COVID-19-associated ARDS manifesting with pulmonary barotrauma at acceptable ventilatory pressures.
The first patient was a 71-year-old man who was intubated and placed on mechanical ventilation due to hypoxemic respiratory failure from SARS-CoV-2 infection. His partial pressure of O2 to fraction of inspired oxygen ratio (PaO2/FiO2) was 156. He developed subcutaneous emphysema (SE) and pneumomediastinum on day 5 of mechanical ventilation at ventilatory settings of positive end-expiratory pressure (PEEP) ≤15 cmH 2O, plateau pressure (Pplat) ≤25 cmH 2O and pulmonary inspiratory pressure (PIP) ≤30 cmH 2O. He was managed with ‘blow-hole’ incisions, with subsequent clinical resolution of subcutaneous emphysema. The second patient was a 58-year-old woman who was also mechanically ventilated due to hypoxemic respiratory failure from COVID-19, with PaO2/FiO2 of 81. She developed extensive SE with pneumomediastinum and pneumothorax while on mechanical ventilation settings PEEP 13 cmH 2O and PIP 28 cmH 2O, Pplat 18 cmH 2O, and FiO2 90%. SE was managed with blow-hole incisions and pneumothorax with chest tube.