Main Article Content
Pneumothorax, Pneumomediastinum, CPAP, PEEP, COVID-19
Background: Acute Hypoxemic Respiratory Failure (AHRF) is a common complication of Covid-19 related pneumonia, for which non-invasive ventilation (NIV) with Helmet Continuous Positive Airway Pressure (CPAP) is widely used. The frequency of pneumothorax in COVID-19 was reported in 0.95% of hospitalized patients in 6% of mechanically ventilated patients, and in 1% of a post-mortem case series. Objectives: Aim of our retrospective study was to investigate the incidence of pneumothorax and pneumomediastinum (PNX/PNM) in COVID-19 pneumonia patients treated with Helmet CPAP. Moreover, we examined the correlation between PNX/PNM and Positive end-expiratory pressure (PEEP) values. Methods: We collected data from patients admitted to “Luigi Sacco” University Hospital of Milan from 2 February to 5 May 2020 with COVID-19 pneumonia requiring CPAP. Patients, who need endotracheal intubation (ETI) for any reason except those who needed ETI after PNX/PNM, were excluded. Population was divided in two groups according to PEEP level used under CPAP (≤10 cmH2O and >10 cmH20). Results: One hundred fifty-four patients were enrolled. In the overall population, 42 patients (27%) were treated with High-PEEP (>10 cmH2O), and 112 with Low-PEEP (≤10 cmH2O). During hospitalization 3 PNX and 2 PNM occurred (3.2%). Out of these five patients, 2 needed invasive ventilation after PNX and died. All the PNX/PNM occurred in the High-PEEP group (5/37 vs 0/112, p<0,001). Conclusion: The incidence of PNX appears to be lower in COVID-19 than SARS and MERS. Considering the association of PNX/PNM with high PEEP we suggest using the lower PEEP as possible to prevent these complications.
2. Radovanovic D, Rizzi M, Pini S, Saad M, Chiumello DA, Santus P. Helmet CPAP to Treat Acute Hypoxemic Respiratory Failure in Patients with COVID-19: A Management Strategy Proposal. J Clin Med. 2020;9(4):1191. doi:10.3390/jcm9041191
3. YAM LY, CHEN RC, ZHONG NS. SARS: ventilatory and intensive care. Respirology. 2003;8(s1):S31-S35. doi:10.1046/j.1440-1843.2003.00521.x
4. Zhao Z. Description and clinical treatment of an early outbreak of severe acute respiratory syndrome (SARS) in Guangzhou, PR China. J Med Microbiol. 2003;52(8):715-720. doi:10.1099/jmm.0.05320-0
5. Alraddadi BM, Qushmaq I, Al‐Hameed FM, et al. Noninvasive ventilation in critically ill patients with the Middle East respiratory syndrome. Influenza Other Respi Viruses. 2019;13(4):382-390. doi:10.1111/irv.12635
6. Brambilla AM, Prina E, Ferrari G, et al. Non-invasive positive pressure ventilation in pneumonia outside Intensive Care Unit: An Italian multicenter observational study. Eur J Intern Med. 2019;59(August 2018):21-26. doi:10.1016/j.ejim.2018.09.025
7 Brambilla AM, Aliberti S, Prina E, et al. Helmet CPAP vs. oxygen therapy in severe hypoxemic respiratory failure due to pneumonia [published correction appears in Intensive Care Med. 2014 Aug;40(8):1187]. Intensive Care Med. 2014;40(7):942-949. doi:10.1007/s00134-014-3325-5
8 Cabrini L, Landoni G, Zangrillo A. Minimise nosocomial spread of 2019-nCoV when treating acute respiratory failure. Lancet. 2020;395(10225):685. doi:10.1016/S0140-6736(20)30359-7
9. Peiris J, Chu C, Cheng V, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet. 2003;361(9371):1767-1772. doi:10.1016/S0140-6736(03)13412-5
10. Sihoe ADL, Wong RHL, Lee ATH, et al. Severe Acute Respiratory Syndrome Complicated by Spontaneous Pneumothorax. Chest. 2004;125(6):2345-2351. doi:10.1378/chest.125.6.2345
11. Das KM, Lee EY, Jawder SE Al, et al. Acute Middle East Respiratory Syndrome Coronavirus: Temporal Lung Changes Observed on the Chest Radiographs of 55 Patients. Am J Roentgenol. 2015;205(3):W267-S274. doi:10.2214/AJR.15.14445
12. Martinelli AW, Ingle T, Newman J, Nadeem I, Jackson K, Lane ND, et al. COVID-19 and Pneumothorax: A Multicentre Retrospective Case Series. Eur Respir J. 2020. doi: 10.1183/13993003.02697-2020.
13 Yao W, Wang T, Jiang B, et al. Emergency tracheal intubation in 202 patients with
COVID-19 in Wuhan, China: lessons learnt and international expert recommendations. Br J Anaesth. 2020;125(1):e28-e37.
14. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with Q17 COVID-19. J Med Virol. In press
15 Parke RL, Eccleston ML, McGuinness SP. The Effects of Flow on Airway Pressure During Nasal High-Flow Oxygen Therapy. Respir Care. 2011;56(8):1151-1155. doi:10.4187/respcare.01106
16. Miró Ò, Llorens P, Jiménez S, et al Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study. Chest. 2020 Nov 20:S0012-3692(20)35201-6. doi: 10.1016/j.chest.2020.11.013. Epub ahead of print. PMID: 33227276; PMCID: PMC7678420.
17. Kangas-Dick A, Gazivoda V, Ibrahim M, Sun A, Shaw JP, Brichkov I, et al. Clinical Characteristics and Outcome of Pneumomediastinum in Patients with COVID-19 Pneumonia. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2020. doi: 10.1089/lap.2020.0692
18. Müller NL, Ooi GC, Khong PL, Zhou LJ, Tsang KWT, Nicolaou S. High-Resolution CT Findings of Severe Acute Respiratory Syndrome at Presentation and after Admission. Am J Roentgenol. 2004;182(1):39-44. doi:10.2214/ajr.182.1.1820039
19. Franks TJ, Chong PEKY, Chui P, et al. Lung Pathology of Severe Acute Respiratory Syndrome ( SARS ): A Study of 8 Autopsy Cases From Singapore. Hum Pathol. 2003;(August). doi:10.1016/S0046-8177(03)00367-8
20. Lei P, Mao J, Wang P. Spontaneous Pneumomediastinum in a Patient with Coronavirus Disease 2019 Pneumonia and the Possible Underlying Mechanism. Korean J Radiol. 2020;21(7):929. doi:10.3348/kjr.2020.0426
21. Carsana L, Sonzogni A, Nasr A, et al. Articles Pulmonary post-mortem findings in a series of COVID-19 cases from northern Italy : a two-centre descriptive study. Lancet Infect Dis. 2020;3099(20):6-11. doi:10.1016/S1473-3099(20)30434-5