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Bajto P, Saric I, Bugarin JD, Delic N, Dosenovic S, Ilic D, Stipic SS, Duplancic B, Saric L. Barotrauma in patients with severe coronavirus disease 2019-retrospective observational study. J Thorac Dis 2023; 15:5297-5306. [PMID: 37969263 PMCID: PMC10636462 DOI: 10.21037/jtd-23-677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/18/2023] [Indexed: 11/17/2023]
Abstract
Background Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Although it is known that the COVID-19 acute respiratory distress syndrome (ARDS) is associated with higher incidence of pulmonary barotrauma, unique mechanisms causing the aforementioned complication are still to be investigated. The goal of this research was to investigate the incidence of barotrauma among COVID-19 patients treated in the intensive care unit (ICU) and to examine different clinical outcomes among those subjects. Methods This retrospective observational cohort study included adult COVID-19 patients admitted to ICU from September 1, 2020, to February 28, 2022. All admitted subjects received invasive respiratory support. Subjects were divided into two groups based on occurrence of pulmonary barotrauma. Data were collected from available electronical medical records. Results In the study period, a total of 900 subjects met inclusion criteria. Pulmonary barotrauma occurred in 88 (9.8%) of them. Subcutaneous emphysema developed in 73 (83%), pneumomediastinum in 68 (77.3%) and pneumothorax in 54 (61.4%) subjects. A small group of subjects developed less common complications like pneumoperitoneum (8 subjects, 9.1%) and pneumopericardium (2 subjects, 2.3%). Survival rate was higher in control than in barotrauma group [396 (48.8%) vs. 22 (25.0%), P<0.05]. There was also a significant difference between two groups in PaO2/FiO2 ratio on admission, duration of non-invasive respiratory support before mechanical ventilation, duration of mechanical ventilation and duration of ICU and hospital stay, all in favour of control group. Conclusions Development of barotrauma in patients with severe forms of COVID-19 disease and in need of respiratory support is associated with longer ICU and hospital stay as well as lower survival rates at hospital discharge. Further efforts are needed in understanding mechanism in developing barotrauma and finding new prevention and treatment options.
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Affiliation(s)
- Petra Bajto
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Ivana Saric
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Josipa Domazet Bugarin
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Nikola Delic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Svjetlana Dosenovic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Darko Ilic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Sanda Stojanovic Stipic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Bozidar Duplancic
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Lenko Saric
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
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2
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Zhong Z, Guo J, Li X, Han Y. Effects of pulmonary air leak on patients with coronavirus disease 2019 (COVID-19): a systematic review and meta-analysis. BMC Pulm Med 2023; 23:398. [PMID: 37858100 PMCID: PMC10588255 DOI: 10.1186/s12890-023-02710-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/13/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has posed increasing challenges to global health systems. We aimed to understand the effects of pulmonary air leak (PAL), including pneumothorax, pneumomediastinum and subcutaneous emphysema, on patients with COVID-19. METHODS We searched PubMed, Embase and Web of Science for data and performed a meta-analysis with a random-effects model using Stata 14.0. This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Thirty-five articles were included in the meta-analysis. The data came from 14 countries and included 3,047 COVID-19 patients with PAL, 11,3679 COVID-19 patients without PAL and 361 non-COVID-19 patients with PAL. We found that the incidence of PAL was much higher in COVID-19 patients than in non-COVID-19 patients (odds ratio (OR) = 6.13, 95% CI: 2.09-18.00). We found that the group of COVID-19 patients with PAL had a longer hospital stay (standardized mean difference (SMD) = 0.79, 95% CI: 0.27-1.30) and intensive care unit (ICU) stay (SMD = 0.51, 95% CI: 0.19-0.83) and comprised more ICU (OR = 15.16, 95% CI: 6.51-35.29) and mechanical ventilation patients (OR = 5.52, 95% CI: 1.69-17.99); furthermore, the mortality rate was also higher (OR = 2.62, 95% CI: 1.80-3.82). CONCLUSIONS Patients with lung injuries caused by COVID-19 may develop PAL. COVID-19 patients with PAL require more medical resources, have more serious conditions and have worse clinical outcomes. PROSPERO REGISTRATION NUMBER CRD42022365047.
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Affiliation(s)
- Zhuan Zhong
- The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jia Guo
- China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Xingzhao Li
- China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Yingying Han
- China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China.
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Al Lawati R, Al Lawati F, Al Battashi N, Al Umairi R, Al Ajmi E, Al Lawati N. Case Series on Barotrauma in COVID-19 Infection Patients. Oman Med J 2023; 38:e557. [PMID: 38192363 PMCID: PMC10772361 DOI: 10.5001/omj.2023.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 09/04/2022] [Indexed: 01/10/2024] Open
Abstract
As COVID-19 emerged in the world, there was a high prevalence of intubation and intensive care admissions. Many cases of barotrauma were reported in those patients. This condition is caused by alveoli rupture, which causes the air to enter the surrounding extra-alveolar spaces. It mainly happens in intubated patients. Here, we report 14 cases of barotrauma in COVID-19 patients, which appeared either spontaneously or after receiving non-invasive ventilation, some of the patients presented initially with mild-moderate forms of the disease in terms of severity. Developing barotrauma causes a management challenge in COVID-19 patients, where the patients might require invasive mechanical ventilation afterwards, which is a difficult situation. Lung protective measures should be used to reduce the risk of barotrauma in all patients as it is associated with increased mortality.
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Affiliation(s)
| | - Fatma Al Lawati
- Internal Medicine Department, Pulmonology Unit, Sultan Qaboos University Hospital, Muscat, Oman
| | | | | | - Eiman Al Ajmi
- Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
| | - Nabil Al Lawati
- Chest and Sleep Medicine, COVID-19 Field Hospital, Muscat, Oman
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4
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Miyake N, Igarashi Y, Nakae R, Mizobuchi T, Masuno T, Yokobori S. Ventilator management and risk of air leak syndrome in patients with SARS-CoV-2 pneumonia: a single-center, retrospective, observational study. BMC Pulm Med 2023; 23:251. [PMID: 37430221 DOI: 10.1186/s12890-023-02549-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is reportedly associated with air leak syndrome (ALS), including mediastinal emphysema and pneumothorax, and has a high mortality rate. In this study, we compared values obtained every minute from ventilators to clarify the relationship between ventilator management and risk of developing ALS. METHODS This single-center, retrospective, observational study was conducted at a tertiary care hospital in Tokyo, Japan, over a 21-month period. Information on patient background, ventilator data, and outcomes was collected from adult patients with SARS-CoV-2 pneumonia on ventilator management. Patients who developed ALS within 30 days of ventilator management initiation (ALS group) were compared with those who did not (non-ALS group). RESULTS Of the 105 patients, 14 (13%) developed ALS. The median positive-end expiratory pressure (PEEP) difference was 0.20 cmH2O (95% confidence interval [CI], 0.20-0.20) and it was higher in the ALS group than in the non-ALS group (9.6 [7.8-20.2] vs. 9.3 [7.3-10.2], respectively). For peak pressure, the median difference was -0.30 cmH2O (95% CI, -0.30 - -0.20) (20.4 [17.0-24.4] in the ALS group vs. 20.9 [16.7-24.6] in the non-ALS group). The mean pressure difference of 0.0 cmH2O (95% CI, 0.0-0.0) (12.7 [10.9-14.6] vs. 13.0 [10.3-15.0], respectively) was also higher in the non-ALS group than in the ALS group. The difference in single ventilation volume per ideal body weight was 0.71 mL/kg (95% CI, 0.70-0.72) (8.17 [6.79-9.54] vs. 7.43 [6.03-8.81], respectively), and the difference in dynamic lung compliance was 8.27 mL/cmH2O (95% CI, 12.76-21.95) (43.8 [28.2-68.8] vs. 35.7 [26.5-41.5], respectively); both were higher in the ALS group than in the non-ALS group. CONCLUSIONS There was no association between higher ventilator pressures and the development of ALS. The ALS group had higher dynamic lung compliance and tidal volumes than the non-ALS group, which may indicate a pulmonary contribution to ALS. Ventilator management that limits tidal volume may prevent ALS development.
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Affiliation(s)
- Nodoka Miyake
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Yutaka Igarashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Taiki Mizobuchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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5
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Lee SJ, Kim J, Lee KH, Lee JA, Kim CH, Lee SH, Park BJ, Kim JH, Ahn JY, Jeong SJ, Ku NS, Yeom JS, Choi JY. Risk factors of pneumothorax and pneumomediastinum in COVID-19: a matched case-control study. BMC Infect Dis 2023; 23:137. [PMID: 36882735 PMCID: PMC9990560 DOI: 10.1186/s12879-023-08104-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 02/20/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND During the novel coronavirus disease-2019 pandemic, a considerable number of pneumothorax (PNX)/pneumomediastinum (PNM) associated with COVID-19 have been reported, and the incidence is higher in critically ill patients. Despite using a protective ventilation strategy, PNX/PNM still occurs in patients on invasive mechanical ventilation (IMV). This matched case-control study aims to identify the risk factors and clinical characteristics of PNX/PNM in COVID-19. METHODS This retrospective study enrolled adult patients with COVID-19, admitted to a critical care unit from March 1, 2020, to January 31, 2022. COVID-19 patients with PNX/PNM were compared, in a 1-2 ratio, to COVID-19 patients without PNX/PNM, matched for age, gender, and worst National Institute of Allergy and Infectious Diseases ordinal scale. Conditional logistic regression analysis was performed to assess the risk factors for PNX/PNM in COVID-19. RESULTS 427 patients with COVID-19 were admitted during the period, and 24 patients were diagnosed with PNX/PNM. Body mass index (BMI) was significantly lower in the case group (22.8 kg/m2 and 24.7 kg/m2; P = 0.048). BMI was statistically significant risk factor for PNX/PNM in univariate conditional logistic regression analysis [odds ratio (OR), 0.85; confidence interval (CI), 0.72-0.996; P = 0.044]. For patients on IMV support, univariate conditional logistic regression analysis showed the statistical significance of the duration from symptom onset to intubation (OR, 1.14; CI, 1.006-1.293; P = 0.041). CONCLUSIONS Higher BMI tended to show a protective effect against PNX/PNM due to COVID-19 and delayed application of IMV might be a contributive factor for this complication.
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Affiliation(s)
- Se Ju Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Jinnam Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ki Hyun Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Ah Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Hyup Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Su Hwan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Jo Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Ho Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Young Ahn
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nam Su Ku
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon-Sup Yeom
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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6
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Occurrence, Risk Factors, and Outcomes of Pulmonary Barotrauma in Critically Ill COVID-19 Patients: A Retrospective Cohort Study. Crit Care Res Pract 2023; 2023:4675910. [PMID: 36875553 PMCID: PMC9977517 DOI: 10.1155/2023/4675910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/02/2023] [Accepted: 01/23/2023] [Indexed: 02/25/2023] Open
Abstract
Objective Pulmonary barotrauma has been frequently observed in patients with COVID-19 who present with acute hypoxemic respiratory failure. This study evaluated the prevalence, risk factors, and outcomes of barotrauma in patients with COVID-19 requiring ICU admission. Methods This retrospective cohort study included patients with confirmed COVID-19 who were admitted to an adult ICU between March and December 2020. We compared patients who had barotrauma with those who did not. A multivariable logistic regression analysis was performed to determine the predictors of barotrauma and hospital mortality. Results Of 481 patients in the study cohort, 49 (10.2%, 95% confidence interval: 7.6-13.2%) developed barotrauma on a median of 4 days after ICU admission. Barotrauma manifested as pneumothorax (N = 21), pneumomediastinum (N = 25), and subcutaneous emphysema (N = 25) with frequent overlap. Chronic comorbidities and inflammatory markers were similar in both patient groups. Barotrauma occurred in 4/132 patients (3.0%) who received noninvasive ventilation without intubation, and in 43/280 patients (15.4%) who received invasive mechanical ventilation. Invasive mechanical ventilation was the only risk factor for barotrauma (odds ratio: 14.558, 95% confidence interval: 1.833-115.601). Patients with barotrauma had higher hospital mortality (69.4% versus 37.0%; p < 0.0001) and longer duration of mechanical ventilation and ICU stay. Barotrauma was an independent predictor of hospital mortality (odds ratio: 2.784, 95% confidence interval: 1.310-5.918). Conclusion s. Barotrauma was common in critical COVID-19, with invasive mechanical ventilation being the most prominent risk factor. Barotrauma was associated with poorer clinical outcomes and was an independent predictor of hospital mortality.
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7
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Andrews P, Shiber J, Madden M, Nieman GF, Camporota L, Habashi NM. Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal. Front Physiol 2022; 13:928562. [PMID: 35957991 PMCID: PMC9358044 DOI: 10.3389/fphys.2022.928562] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/21/2022] [Indexed: 12/16/2022] Open
Abstract
In the pursuit of science, competitive ideas and debate are necessary means to attain knowledge and expose our ignorance. To quote Murray Gell-Mann (1969 Nobel Prize laureate in Physics): “Scientific orthodoxy kills truth”. In mechanical ventilation, the goal is to provide the best approach to support patients with respiratory failure until the underlying disease resolves, while minimizing iatrogenic damage. This compromise characterizes the philosophy behind the concept of “lung protective” ventilation. Unfortunately, inadequacies of the current conceptual model–that focuses exclusively on a nominal value of low tidal volume and promotes shrinking of the “baby lung” - is reflected in the high mortality rate of patients with moderate and severe acute respiratory distress syndrome. These data call for exploration and investigation of competitive models evaluated thoroughly through a scientific process. Airway Pressure Release Ventilation (APRV) is one of the most studied yet controversial modes of mechanical ventilation that shows promise in experimental and clinical data. Over the last 3 decades APRV has evolved from a rescue strategy to a preemptive lung injury prevention approach with potential to stabilize the lung and restore alveolar homogeneity. However, several obstacles have so far impeded the evaluation of APRV’s clinical efficacy in large, randomized trials. For instance, there is no universally accepted standardized method of setting APRV and thus, it is not established whether its effects on clinical outcomes are due to the ventilator mode per se or the method applied. In addition, one distinctive issue that hinders proper scientific evaluation of APRV is the ubiquitous presence of myths and misconceptions repeatedly presented in the literature. In this review we discuss some of these misleading notions and present data to advance scientific discourse around the uses and misuses of APRV in the current literature.
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Affiliation(s)
- Penny Andrews
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
- *Correspondence: Penny Andrews,
| | - Joseph Shiber
- University of Florida College of Medicine, Jacksonville, FL, United States
| | - Maria Madden
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, United Kingdom
| | - Nader M. Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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8
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Brioni M, Meli A, Grasselli G. Mechanical Ventilation for COVID-19 Patients. Semin Respir Crit Care Med 2022; 43:405-416. [PMID: 35439831 DOI: 10.1055/s-0042-1744305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Non-invasive ventilation (NIV) or invasive mechanical ventilation (MV) is frequently needed in patients with acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While NIV can be delivered in hospital wards and nonintensive care environments, intubated patients require intensive care unit (ICU) admission and support. Thus, the lack of ICU beds generated by the pandemic has often forced the use of NIV in severely hypoxemic patients treated outside the ICU. In this context, awake prone positioning has been widely adopted to ameliorate oxygenation during noninvasive respiratory support. Still, the incidence of NIV failure and the role of patient self-induced lung injury on hospital outcomes of COVID-19 subjects need to be elucidated. On the other hand, endotracheal intubation is indicated when gas exchange deterioration, muscular exhaustion, and/or neurological impairment ensue. Yet, the best timing for intubation in COVID-19 is still widely debated, as it is the safest use of neuromuscular blocking agents. Not differently from other types of acute respiratory distress syndrome, the aim of MV during COVID-19 is to provide adequate gas exchange while avoiding ventilator-induced lung injury. At the same time, the use of rescue therapies is advocated when standard care is unable to guarantee sufficient organ support. Nevertheless, the general shortage of health care resources experienced during SARS-CoV-2 pandemic might affect the utilization of high-cost, highly specialized, and long-term supports. In this article, we describe the state-of-the-art of NIV and MV setting and their usage for acute hypoxemic respiratory failure of COVID-19 patients.
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Affiliation(s)
- Matteo Brioni
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Meli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Paternoster G, Bertini P, Belletti A, Landoni G, Gallotta S, Palumbo D, Isirdi A, Guarracino F. Veno-Venous Extracorporeal Membrane Oxygenation in Awake Non-Intubated Patients with COVID-19 ARDS at High Risk for Barotrauma. J Cardiothorac Vasc Anesth 2022; 36:2975-2982. [PMID: 35537972 PMCID: PMC8926433 DOI: 10.1053/j.jvca.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 12/16/2022]
Abstract
Objectives: To assess the efficacy of an awake venovenous extracorporeal membrane oxygenation (VV-ECMO) management strategy in preventing clinically relevant barotrauma in patients with coronavirus disease 2019 (COVID-19) with severe acute respiratory distress syndrome (ARDS) at high risk for pneumothorax (PNX)/pneumomediastinum (PMD), defined as the detection of the Macklin-like effect on chest computed tomography (CT) scan. Design: A case series. Setting: At the intensive care unit of a tertiary-care institution. Participants: Seven patients with COVID-19-associated severe ARDS and Macklin-like radiologic sign on baseline chest CT. Interventions: Primary VV-ECMO under spontaneous breathing instead of invasive mechanical ventilation (IMV). All patients received noninvasive ventilation or oxygen through a high-flow nasal cannula before and during ECMO support. The study authors collected data on cannulation strategy, clinical management, and outcome. Failure of awake VV-ECMO strategy was defined as the need for IMV due to worsening respiratory failure or delirium/agitation. The primary outcome was the development of PNX/PMD. Measurements and Main Results: No patient developed PNX/PMD. The awake VV-ECMO strategy failed in 1 patient (14.3%). Severe complications were observed in 4 (57.1%) patients and were noted as the following: intracranial bleeding in 1 patient (14.3%), septic shock in 2 patients (28.6%), and secondary pulmonary infections in 3 patients (42.8%). Two patients died (28.6%), whereas 5 were successfully weaned off VV-ECMO and were discharged home. Conclusions: VV-ECMO in awake and spontaneously breathing patients with severe COVID-19 ARDS may be a feasible and safe strategy to prevent the development of PNX/PMD in patients at high risk for this complication.
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10
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Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in non-ventilated COVID-19 patients. Future Sci OA 2022; 8:FSO771. [PMID: 35059221 PMCID: PMC8609960 DOI: 10.2144/fsoa-2021-0090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/02/2021] [Indexed: 01/08/2023] Open
Abstract
Aim: Pneumothorax (PNX), pneumomediastinum (PMD) and subcutaneous emphysema (SCE) are COVID-19 complications related to positive-pressure ventilation. We analyzed the pathophysiology of these complications without ventilation. Patients & methods: Out of 1845 admitted COVID-19 patients, we retrospectively collected data for 15 patients, from a tertiary medical center, from 1 October 2020 to 31 March 2021. Results: Five patients suffered from spontaneous PNX, 8/15 developed PMD and 8/15 developed SCE. The mean BMI was 29.7, as most patients were obese or overweight. Most patients had lymphocytopenia and increased C-reactive protein, ferritin and lactate dehydrogenase levels. Eleven patients succumbed to the disease. Conclusion: Risk factors of spontaneous PNX, PMD and SCE in COVID-19 patients need further investigations by conducting more comprehensive case–control studies. We have investigated spontaneous alveolar rupture as a complication in 15 COVID-19 patients. Manifested as pneumothorax, pneumomediastinum and subcutaneous emphysema, these complications are less common in patients without mechanical ventilation. Management of these patients was either conservative or by insertion of a chest tube. Eventually, 11 out of 15 patients have passed away due to respiratory failure.
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11
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Tetaj N, Garotto G, Albarello F, Mastrobattista A, Maritti M, Stazi GV, Marini MC, Caravella I, Macchione M, De Angelis G, Busso D, Di Lorenzo R, Scarcia S, Farina A, Centanni D, Vargas J, Savino M, Carucci A, Antinori A, Palmieri F, D’Offizi G, Ianniello S, Taglietti F, Campioni P, Vaia F, Nicastri E, Girardi E, Marchioni L. Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate-Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital. J Clin Med 2021; 10:5608. [PMID: 34884310 PMCID: PMC8658701 DOI: 10.3390/jcm10235608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 11/25/2021] [Accepted: 11/27/2021] [Indexed: 01/12/2023] Open
Abstract
(1) Background: COVID-19 is a novel cause of acute respiratory distress syndrome (ARDS). Indeed, with the increase of ARDS cases due to the COVID-19 pandemic, there has also been an increase in the incidence of cases with pneumothorax (PNX) and pneumomediastinum (PNM). However, the incidence and the predictors of PNX/PMN in these patients are currently unclear and even conflicting. (2) Methods: The present observational study analyzed the incidence of barotrauma (PNX/PNM) in COVID-19 patients with moderate-severe ARDS hospitalized in a year of the pandemic, also focusing on the three waves occurring during the year, and treated with positive-pressure ventilation (PPV). We collected demographic and clinical data. (3) Results: During this period, 40 patients developed PNX/PNM. The overall incidence of barotrauma in all COVID-19 patients hospitalized in a year was 1.6%, and in those with moderate-severe ARDS in PPV was 7.2% and 3.8 events per 1000 positive-pressure ventilator days. The incidence of barotrauma in moderate-severe ARDS COVID-19 patients during the three waves was 7.8%, 7.4%, and 8.7%, respectively. Treatment with noninvasive respiratory support alone was associated with an incidence of barotrauma of 9.1% and 2.6 events per 1000 noninvasive ventilator days, of which 95% were admitted to the ICU after the event, due to a worsening of respiratory parameters. The incidence of barotrauma of ICU COVID-19 patients in invasive ventilation over a year was 5.8% and 2.7 events per 1000 invasive ventilator days. There was no significant difference in demographics and clinical features between the barotrauma and non-barotrauma group. The mortality was higher in the barotrauma group (17 patients died, 47.2%) than in the non-barotrauma group (170 patients died, 37%), although this difference was not statistically significant (p = 0.429). (4) Conclusions: The incidence of PNX/PNM in moderate-severe ARDS COVID-19 patients did not differ significantly between the three waves over a year, and does not appear to be very different from that in ARDS patients in the pre-COVID era. The barotrauma does not appear to significantly increase mortality in COVID-19 patients with moderate-severe ARDS if protective ventilation strategies are applied. Attention should be paid to the risk of barotrauma in COVID-19 patients in noninvasive ventilation because the event increases the probability of admission to the intensive care unit (ICU) and intubation.
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Affiliation(s)
- Nardi Tetaj
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Gabriele Garotto
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Fabrizio Albarello
- Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (F.A.); (S.I.); (P.C.)
| | - Annelisa Mastrobattista
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (A.M.); (F.P.)
| | - Micaela Maritti
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Giulia Valeria Stazi
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Maria Cristina Marini
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Ilaria Caravella
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Manuela Macchione
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Giada De Angelis
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Donatella Busso
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Rachele Di Lorenzo
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Silvana Scarcia
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Anna Farina
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Daniele Centanni
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Joel Vargas
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (J.V.); (M.S.)
| | - Martina Savino
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (J.V.); (M.S.)
| | - Alessandro Carucci
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
| | - Andrea Antinori
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Fabrizio Palmieri
- Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (A.M.); (F.P.)
| | - Gianpiero D’Offizi
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Stefania Ianniello
- Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (F.A.); (S.I.); (P.C.)
| | - Fabrizio Taglietti
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Paolo Campioni
- Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (F.A.); (S.I.); (P.C.)
| | - Francesco Vaia
- Health Direction, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy;
| | - Emanuele Nicastri
- Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy; (D.C.); (A.A.); (G.D.); (F.T.); (E.N.)
| | - Enrico Girardi
- Scientific Direction, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy;
| | - Luisa Marchioni
- UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy; (G.G.); (M.M.); (G.V.S.); (M.C.M.); (I.C.); (M.M.); (G.D.A.); (D.B.); (R.D.L.); (S.S.); (A.F.); (A.C.); (L.M.)
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12
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Gutierrez-Ariza JC, Rodriguez Yanez T, Martinez-Ávila MC, Almanza Hurtado A, Dueñas-Castell C. Pneumomediastinum and Pneumothorax Following Non-invasive Respiratory Support in Patients With Severe COVID-19 Disease. Cureus 2021; 13:e18796. [PMID: 34796074 PMCID: PMC8590743 DOI: 10.7759/cureus.18796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 11/05/2022] Open
Abstract
The coronavirus disease-2019 (COVID-19) pandemic led to an increased number of patients with pneumothorax and pneumomediastinum owing to complications attributed to viral pneumonia regardless of the use of mechanical invasive ventilation and the elapsed time of infection. The pathophysiology remains unknown. However, the Macklin effect is shown as the most plausible mechanism along with possible barotrauma secondary to a high-flow nasal cannula and noninvasive mechanical ventilation. We present two cases of patients who developed pneumomediastinum and tension pneumothorax. One of the patients was studied during infection and the other after recovery. Both received appropriate and timely treatments with successful outcomes. It is important to be aware of these potentially fatal complications as early management can reduce the associated morbidity and mortality.
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13
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Kalpaxi A, Kalokairinou M, Katseli P, Savvopoulou V, Ioannidi P, Triantafyllou E, Flokatoula M, Pythara C, Papaevangelou A. Spontaneous pneumomediastinum and COVID-19 pneumonia: Report of three cases with emphasis on CT imaging. Radiol Case Rep 2021; 16:2586-2592. [PMID: 34178187 PMCID: PMC8220909 DOI: 10.1016/j.radcr.2021.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 02/07/2023] Open
Abstract
Spontaneous pneumomediastinum is a rare complication of coronavirus disease 2019. The published literature consists mainly of case reports and small case series. There are still many questions regarding the pathogenesis, the prognostic significance and the implications on patient management. In our hospital, 3 coronavirus disease 2019 patients developed spontaneous pneumomediastinum: 1 on admission at the emergency department and the other 2 during hospitalization. In this study we describe their clinical course and computed tomography (CT) findings. All of them had severe disease according to the total severity score on admission CT. The management of pneumomediastinum was conservative and follow-up CT showed resolution in all patients. As the correlation between extension of parenchymal lung lesions and development of pneumomediastinum is still under investigation, we highlight the importance of reporting the severity score on chest CT in order to obtain more comparable results between different studies. Furthermore, in this tragic circumstance we also had the opportunity to familiarize ourselves with the otherwise uncommon occurrence of air along the bronchovascular sheaths (Macklin effect) and evaluate the ability of CT to detect it.
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Affiliation(s)
- Angeliki Kalpaxi
- Department of Radiology, Thriassio General Hospital of Elefsina, Gennimata Avenue 19600, Magoula, Athens 19600, Greece
| | - Mariana Kalokairinou
- Department of Radiology, Thriassio General Hospital of Elefsina, Gennimata Avenue 19600, Magoula, Athens 19600, Greece
| | - Paraskevi Katseli
- Department of Internal Medicine, Thriassio General Hospital of Elefsina, Magoula, Athens, Greece
| | - Vasiliki Savvopoulou
- Department of Radiology, Thriassio General Hospital of Elefsina, Gennimata Avenue 19600, Magoula, Athens 19600, Greece
| | - Pinelopi Ioannidi
- Department of Radiology, Thriassio General Hospital of Elefsina, Gennimata Avenue 19600, Magoula, Athens 19600, Greece
| | - Evangelia Triantafyllou
- Department of Radiology, Thriassio General Hospital of Elefsina, Gennimata Avenue 19600, Magoula, Athens 19600, Greece
| | - Maria Flokatoula
- Department of Radiology, Thriassio General Hospital of Elefsina, Gennimata Avenue 19600, Magoula, Athens 19600, Greece
| | - Chrystalla Pythara
- Department of Radiology, Thriassio General Hospital of Elefsina, Gennimata Avenue 19600, Magoula, Athens 19600, Greece
| | - Angeliki Papaevangelou
- Department of Radiology, Thriassio General Hospital of Elefsina, Gennimata Avenue 19600, Magoula, Athens 19600, Greece
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