A Case Series of Secondary Spontaneous Pneumomediastinum and Pneumothorax in Severe COVID-19 Pneumonia

Peter P Staiano; Shaorinkumar Patel; Kevin R Green; Mariam Louis; Hadi Hatoum

doi:10.7759/cureus.22247

A Case Series of Secondary Spontaneous Pneumomediastinum and Pneumothorax in Severe COVID-19 Pneumonia

Cureus. 2022 Feb 15;14(2):e22247. doi: 10.7759/cureus.22247. eCollection 2022 Feb.

Authors

Peter P Staiano¹, Shaorinkumar Patel², Kevin R Green¹, Mariam Louis³, Hadi Hatoum³

Affiliations

¹ Pulmonary and Critical Care Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA.
² Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA.
³ Pulmonology, University of Florida College of Medicine - Jacksonville, Jacksonville, USA.

Abstract

Introduction Pneumomediastinum and pneumothorax are uncommon complications in COVID-19 patients. The exact prevalence, etiology, and outcomes are not well known. We report a case series of patients in our institution with COVID-19 related pneumomediastinum and pneumothorax and address these questions. Methods We conducted a single-center retrospective chart review of patients admitted at our institution with a positive polymerase chain reaction (PCR) confirming the diagnosis of COVID-19. A cohort of 500 potential study candidates was identified, of whom eight were investigated. Demographic data, hospital course, patient co-morbidities, and outcome data were collected. Results Eight patients were included in our study who were identified as having an event (i.e., pneumomediastinum and/or pneumothorax) during the specified timeframe. Overall, 62% of patients were on high-flow nasal cannula with an average FiO₂ of >70%. The average oxygen saturation//fraction of inspired oxygen (SpO₂/FiO₂) ratio leading up to an event was 113.7286 (range: 101.11-130.66), and all of the patients not on mechanical ventilation met the criteria for acute respiratory distress syndrome (ARDS) based on the Kigali definition with SpO₂/FiO₂ < 315. The three patients who developed an event while requiring mechanical ventilation both had PaO₂/FiO₂ < 100, consistent with severe ARDS at the time of an event. The mean time in days, counted from the day of hospital admission until an event, was 10 days (range: 3-23 days). None of the cases had documented pulmonary parenchymal disease prior to developing COVID-19. To the best of our knowledge, these events were not iatrogenic in nature. Conclusion Secondary spontaneous pneumomediastinum and pneumothorax are rare albeit well-documented phenomena in hospitalized patients with COVID-19 infection. Interestingly, the majority of patients in our study were on high-flow nasal cannula at the time of an event. The majority of previously published data on this topic are on those who required positive pressure ventilation; however, there have been more recent papers that also describe these events in non-mechanically ventilated patients. The exact pathophysiology remains unknown, but it is likely multifactorial, and additional studies are needed to further evaluate this phenomenon.

Keywords: covid-19; high-flow nasal cannula; icu; pneumomediastinum; pneumothorax.