Pulmonary Barotrauma Resulting from Mechanical Ventilation in 2 Patients with a Diagnosis of COVID-19 Pneumonia

Abstract

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

Objective:

Unusual clinical course

Background:

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.

Case Reports:

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.

Conclusions:

Clinicians should be aware of pulmonary barotrauma as a possible complication of COVID-19 pulmonary disease, even at low ventilatory pressures.