Predictors of Pneumothorax/Pneumomediastinum in Mechanically Ventilated COVID-19 Patients

Alessandro Belletti, Diego Palumbo, Alberto Zangrillo, Evgeny V Fominskiy, Stefano Franchini, Antonio Dell'Acqua, Alessandro Marinosci, Giacomo Monti, Giordano Vitali, Sergio Colombo, Giorgia Guazzarotti, Rosalba Lembo, Nicolò Maimeri, Carolina Faustini, Renato Pennella, Junaid Mushtaq, Giovanni Landoni, Anna Mara Scandroglio, Lorenzo Dagna, Francesco De Cobelli, COVID-BioB Study Group, Alessandro Belletti, Diego Palumbo, Alberto Zangrillo, Evgeny V Fominskiy, Stefano Franchini, Antonio Dell'Acqua, Alessandro Marinosci, Giacomo Monti, Giordano Vitali, Sergio Colombo, Giorgia Guazzarotti, Rosalba Lembo, Nicolò Maimeri, Carolina Faustini, Renato Pennella, Junaid Mushtaq, Giovanni Landoni, Anna Mara Scandroglio, Lorenzo Dagna, Francesco De Cobelli, COVID-BioB Study Group

Abstract

Objective: To determine the incidence, predictors, and outcome of pneumothorax (PNX)/pneumomediastinum (PMD) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS).

Design: Observational study.

Setting: Tertiary-care university hospital.

Participants: One hundred sixteen consecutive critically ill, invasively ventilated patients with COVID-19 ARDS.

Interventions: The authors collected demographic, mechanical ventilation, imaging, laboratory, and outcome data. Primary outcome was the incidence of PNX/PMD. Multiple logistic regression analyses were performed to identify predictors of PNX/PMD.

Measurements and main results: PNX/PMD occurred in a total of 28 patients (24.1%), with 22 patients developing PNX (19.0%) and 13 developing PMD (11.2%). Mean time to development of PNX/PMD was 14 ± 11 days from intubation. The authors found no significant difference in mechanical ventilation parameters between patients who developed PNX/PMD and those who did not. Mechanical ventilation parameters were within recommended limits for protective ventilation in both groups. Ninety-five percent of patients with PNX/PMD had the Macklin effect (linear collections of air contiguous to the bronchovascular sheaths) on a baseline computed tomography scan, and tended to have a higher lung involvement at intensive care unit (ICU) admission (Radiographic Assessment of Lung Edema score 32.2 ± 13.4 v 18.7 ± 9.8 in patients without PNX/PMD, p = 0.08). Time from symptom onset to intubation and time from total bilirubin on day two after ICU admission were the only independent predictors of PNX/PMD. Mortality was 60.7% in patients who developed PNX/PMD versus 38.6% in those who did not (p = 0.04).

Conclusion: PNX/PMD occurs frequently in COVID-19 patients with ARDS requiring mechanical ventilation, and is associated with increased mortality. Development of PNX/PMD seems to occur despite use of protective mechanical ventilation and has a radiologic predictor sign.

Keywords: COVID-19; Macklin effect; SARS-CoV-2; acute respiratory distress syndrome; barotrauma; mechanical ventilation; pneumothorax.

Copyright © 2021 Elsevier Inc. All rights reserved.

Figures

Fig 1
Fig 1
Study flow chart with radiologic findings. Abbreviations: ARDS, acute respiratory distress syndrome; COVID-19, coronavirus disease 2019; CT, computed tomography; ICU, intensive care unit; IMV, invasive mechanical ventilation; PNX/PMD, pneumothorax/pneumomediastinum.
Fig 2
Fig 2
Lung parenchyma window axial computed tomography scans of 3 patients with severe acute respiratory syndrome coronavirus 2-associated pneumonia presenting Macklin effect (arrows) in association with pneumothorax (A), early pneumomediastinum (B), and full-blown pneumomediastinum along with subcutaneous emphysema (C).

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