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

• DOI: 10.1053/j.jvca.2021.02.008
• Publication Date: 2021-02-07T17:03:48Z
• Authors: 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 Scandro...; Lorenzo Dagna; Francesco De Cobelli
• Keywords: pneumothorax; SARS-CoV-2; COVID-19; Pneumothorax; acute respiratory distress syndrome; mechanical ventilation; barotrauma; Respiration, Artificial; 3. Good health; 03 medical and health sciences; Anesthesiology and Pain Medicine; 0302 clinical medicine; Macklin effect; Humans; Cardiology and Cardiovascular Medicine; Mediastinal Emphysema; Original Research

To determine the incidence, predictors, and outcome of pneumothorax (PNX)/pneumomediastinum (PMD) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS).Observational study.Tertiary-care university hospital.One hundred sixteen consecutive critically ill, invasively ventilated patients with COVID-19 ARDS.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.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).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.