Macklin effect on baseline chest CT scan accurately predicts barotrauma in COVID-19 patients

Gianluca Paternoster, Gianfranco Belmonte, Enrico Scarano, Pietro Rotondo, Diego Palumbo, Alessandro Belletti, Francesco Corradi, Pietro Bertini, Giovanni Landoni, Fabio Guarracino, COVID-Macklin Study Group, Alessandro Isirdi, Diego Costanzo, Matteo Romani, Luigi De Simone, Roberto Mozzo, Alessia Palmaccio, Giorgia Guazzarotti, Renato Pennella, Francesca Calabrese, Gianluca Paternoster, Gianfranco Belmonte, Enrico Scarano, Pietro Rotondo, Diego Palumbo, Alessandro Belletti, Francesco Corradi, Pietro Bertini, Giovanni Landoni, Fabio Guarracino, COVID-Macklin Study Group, Alessandro Isirdi, Diego Costanzo, Matteo Romani, Luigi De Simone, Roberto Mozzo, Alessia Palmaccio, Giorgia Guazzarotti, Renato Pennella, Francesca Calabrese

Abstract

Purpose: To validate the role of Macklin effect on chest CT imaging in predicting subsequent occurrence of pneumomediastinum/pneumothorax (PMD/PNX) in COVID-19 patients.

Materials and methods: This is an observational, case-control study. Consecutive COVID-19 patients who underwent chest CT scan at hospital admission during the study time period (October 1st, 2020-April 31st, 2021) were identified. Macklin effect accuracy for prediction of spontaneous barotrauma was measured in terms of sensitivity, specificity, positive (PPV) and negative predictive values (NPV).

Results: Overall, 981 COVID-19 patients underwent chest CT scan at hospital arrival during the study time period; 698 patients had radiological signs of interstitial pneumonia and were considered for further evaluation. Among these, Macklin effect was found in 33 (4.7%), including all 32 patients who suffered from barotrauma lately during hospital stay (true positive rate: 96.9%); only 1/33 with Macklin effect did not develop barotrauma (false positive rate: 3.1%). No barotrauma event was recorded in patients without Macklin effect on baseline chest CT scan. Macklin effect yielded a sensitivity of 100% (95% CI: 89.1-100), a specificity of 99.85% (95% CI: 99.2-100), a PPV of 96.7% (95% CI: 80.8-99.5), a NPV of 100% and an accuracy of 99.8% (95% CI: 99.2-100) in predicting PMD/PNX, with a mean advance of 3.2 ± 2.5 days. Moreover, all Macklin-positive patients developed ARDS requiring ICU admission and, in 90.1% of cases, invasive mechanical ventilation.

Conclusions: Macklin effect has high accuracy in predicting PMD/PNX in COVID-19 patients; it is also an excellent predictor of disease severity.

Keywords: Acute respiratory distress syndrome; Barotrauma; Computed tomography; Intensive care; Mechanical ventilation; Pneumomediastinum; Pneumothorax.

Conflict of interest statement

We declare that we do not have conflicts of interest.

Copyright © 2022 Elsevier Ltd. All rights reserved.

Figures

Fig. 1
Fig. 1
Macklin effect in a COVID-19 patient. Lung parenchyma windowed CT images demonstrate [a] a crescent collection of air contiguous to the middle lobar bronchovascular sheath as well as interstitial emphysema in the left upper lobe, both representing Macklin effect (red arrows). Seven days later [b], pneumomediastinum occurred. . (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
Fig. 2
Fig. 2
Lung parenchyma window axial (a) and coronal (b) CT scans of patient suffering from SARS-CoV-2 infection, subjected to invasive mechanics ventilation, show: central Macklin effect (black arrow) in association with pneumomediastinum (white arrow), pneumothorax (white arrow heads), subcutaneous emphysema (black star) and pneumoperitoneum (black arrow head).
Fig. 3
Fig. 3
Inclusion/exclusion flowchart.

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Source: PubMed

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