COVID-19 is an infection that is caused by a new type of coronavirus that was previously not recognized in humans. The first case worldwide was reported in Wuhan, China, in December 2019, and reached Oman in February 2020. The World Health Organization announced the COVID-19 outbreak as a pandemic on 11 March 2020. At the time of writing this report, almost 17 million cases have been reported globally.1

Due to the high prevalence of intubation and intensive care unit (ICU) admissions during the current pandemic of the new COVID-19 era, most of the literature nowadays has reported a high prevalence of barotrauma in patients that developed COVID-19 infection. This could be related to the heightened inflammatory response during this infection, which leads to severe acute lung injury.2

Barotrauma is a condition in which the alveoli rupture with a subsequent entry of air into the surrounding extra-alveolar space.3 Spontaneous pulmonary barotrauma is a pulmonary complication typical in intubated patients. However, in the related viral epidemic of SARS in 2002, 6.6–15% of patients on non-invasive ventilation (NIV) were described to developed pulmonary barotrauma.4 As a result, many studies were conducted regarding developing lung-protective ventilation strategies especially in patients with acute respiratory distress syndrome (ARDS). However, barotrauma continues to be a serious issue posing significant management challenges in ARDS patients.5,6

We present here characteristics of 14 cases of barotrauma during SARS-CoV-2 infection, that appeared either spontaneously or after receiving NIV that presented to the COVID-19 Field Hospital and Sultan Qaboos University Hospital. In our study, we focused only on patients who developed these complications spontaneously during acute COVID-19 infection, with some of them having initially mild/moderate forms of the disease that worsened gradually. The aim of this study was to explore the characteristics of patients hospitalized for COVID-19 who developed pneumothorax (PNX), pneumomediastinum (PM), pneumopericardium (PC), and subcutaneous emphysema (SCE) to better understand factors that seem to influence the evolution and prognosis of these complications.

Case report

We present 14 cases of barotrauma including PNX, PM, PC, and SCE and compared between patients placed on NIV and patients who did not require NIV.

The most common symptoms that our patients presented with were fever, cough, and shortness of breath. One patient was known to have asthma while the others were not diagnosed with any respiratory diseases. Seven (1–7) out of the 14 patients received NIV at some time during their hospital stay, and the other seven (A–G)never used NIV; however, they were kept on ≤ 15 L/minute of oxygen.

The mean age of patients on NIV was 63.5 years. Of the total seven patients, four were female and three were male. One had asthma, while all the others had no underlying lung diseases. Six out of seven patients had PM (Figure 1 – Patient 1, Figure 2 – Patient B, and Figure 3 – Patient D), three had PNX in which intercostal drainage was inserted (Figure 4 – Patient 2), and six patients had SCE (Figure 5 – Patient 6). All had high inflammatory markers including high C-reactive protein, ferritin, and lactate dehydrogenase. However, D-dimer was negative in two of the seven patients. All patients received one dose of intravenous tocilizumab 8 mg/kg. Five out of the seven patients were on continuous positive airway pressure and two were on bi-level positive airway pressure during the development of the barotrauma. The average length of stay (LOS) in hospital was 27.5 days. Four patients were discharged and three died during hospital stay (42.9%) [Table 1].

The mean age of patients who did not require NIV was 51.8 years. PM was seen in all the patients, PNX was observed in one patient who required intercostal drainage insertion, as well as SCE, and PC were noted in two patients. All patients had high inflammatory markers that required tocilizumab. The average LOS was 13.7 days. Five patients were discharged and two were intubated, shifted to ICU then died [Table 2].

The average age was higher in patients who received NIV and developed barotrauma. Patients who received NIV had more PNX and SCE compared to those who did not receive NIV. LOS was longer in patients who received NIV compared to those who did not. The mortality was equal in both groups.

Discussion

Patients with COVID-19 present with a wide spectrum of disease severity from asymptomatic to the need for ICU care and death. Many patients in the ICU need invasive mechanical ventilation (IMV) and/or NIV for the management of ARDS and hypoxemic respiratory failure, which is a common presentation of COVID-19.7

Many case reports and studies demonstrated barotrauma in COVID-19 patients that requires IMV and NIV.2,7,8 It was noticed that SARS-CoV-2 infection increases the risk of barotrauma seven-fold in a study done in Italy, and it was attributed to lung frailty rather than barotrauma, having compared 169 COVID-19 related-ARDS to 163 non-COVID-19 related-ARDS.9

All the barotrauma that happens occur secondary to airway obstruction, use of mechanical ventilation, or if there is a cause that raises the intrathoracic pressure. However, in most COVID-19 patients, these changes were noticed even before any intervention, which is thought to be a consequence of the disease itself.10 One of the mechanisms that is thought to be the cause of barotrauma is that COVID-19 disease causes ischemic lung tissue leading to the formation of pulmonary cysts, which ruptures later and causes PNX, PM, or PC. The other proposed mechanism is self-inflicted lung injury, which is caused by tachypnea.11

PM and SCE are not uncommon in patients affected with COVID-19, and many had a poor outcome which could be because of the nature of the disease rather than the barotrauma per se. However, patients tend to stay longer in hospital with prolonged weaning/treatment de-escalation as well.12

The principal pathophysiologic mechanism of PM is represented by the Macklin phenomenon, explaining the development of an increased pressure gradient between the marginal alveoli and the lung parenchyma, which, in the presence of the extensive alveolar injury, determines air leakage along the surrounding bronchovascular sheaths into the mediastinum. It is known that inflammation could render the alveolar wall more prone to rupture, which could be exacerbated by persistent cough or any factors increasing the intra-alveolar pressure. Some studies included both patients who developed PXN and/or PM spontaneously, as well as those occurring during invasive positive pressure ventilation, where barotrauma could represent the responsible mechanism.13

Eperjesiova et al,14 mentioned that five out of seven of their patients who had spontaneous PM and PNX were intubated. In our case series, one patient was intubated because of the severe COVID-19 infection.

One of the earliest case reports identified a patient with PM which developed within 10 days of admission, this patient was kept on NIV. However, settings were not mentioned, and the patient spent 38 days at the hospital.15

Barotrauma in COVID-19 infection is a challenging issue in the management of affected patients, leading to difficulties in using IMV afterward. Hence, protective lung measures should be used even with the use of NIV to avoid the risk of barotrauma as it was noticed in some studies that it increased the mortality.16,17

Conclusion

Barotrauma is not an uncommon complication of COVID-19 infection. It can occur in all categories of patients, ranging from patients with mild disease to those with critical disease. If barotrauma develops in COVID-19 patients, it causes management challenges; hence, more studies are needed to study the epidemiology and etiology of barotrauma, its relation to COVID-19 pneumonia, and eventually to develop guidelines for prevention and treatment.

Disclosure

The authors declared no conflicts of interest. The ethical approval was obtained from the institiution with Ref number: MoH/CSR/21/24338.

references

1. 1. World Health Organization. Coronavirus disease (COVID-19) pandemic. 2022 [cited 2021 August 22]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019.
2. 2. Kahn MR, Watson RL, Thetford JT, Wong JI, Kamangar N. High incidence of barotrauma in patients with severe coronavirus disease 2019. J Intensive Care Med 2021 Jun;36(6):646-654.
3. 3. William C, Shiel JR. What are the different types of mechanical ventilation? [cited 2021 August 22]. Available from: https://www.medicinenet.com/different_types_of_mechanical_ventilation/article.htm.
4. 4. Pattupara A, Modi V, Goldberg J, Ho KS, Bhatia K, Herrera Y, et al. PULMONARY barotrauma during noninvasive ventilation in patients with COVID-19. Chest 2020 Oct;158(4):A337.
5. 5. Thompson BT, Bernard GR. ARDS network (NHLBI) studies: successes and challenges in ARDS clinical research. Crit Care Clin 2011 Jul;27(3):459-468.
6. 6. Meade MO, Cook DJ, Guyatt GH, Slutsky AS, Arabi YM, Cooper DJ, et al; Lung Open Ventilation Study Investigators. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008 Feb;299(6):637-645.
7. 8. Abdallat M, Khalil M, Al-Awwa G, Kothuru R, Punzina C. Barotrauma in COVID-19 patients. Journal of Lung Health and Diseases 2020 Jun;4(2):8-12.
8. 9. Hamouri S, Samrah SM, Albawaih O, Saleh Z, Smadi MM, Alhazymeh A, et al. Pulmonary barotrauma in COVID-19 patients: invasive versus noninvasive positive pressure ventilation. Int J Gen Med 2021 May;14:2017-2032.
9. 10. Lemmers DH, Abu Hilal M, Bnà C, Prezioso C, Cavallo E, Nencini N, et al. Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty? ERJ Open Res 2020 Nov;6(4):00385-02020.
10. 11. Agrawal A, Sen KK, Satapathy G, Sethi HS, Sharawat A, Reddy DS. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 patients—a case series. Egypt J Radiol Nucl Med 2021 Jan;52(1):1-6.
11. 12. Oye M, Ali A, Kandah F, Chowdhury N. Two cases of spontaneous pneumomediastinum with pneumothorax in patients with COVID-19 associated pneumonia. Respir Med Case Rep 2020;31:101308.
12. 13. Kipourou M, Karozis K, Lampridis S, Gkintikas S, Molyvas D, Koutoukoglou P, et al. Spontaneous pneumomediastinum and subcutaneous emphysema in the course of COVID-19 disease: a case report and review of the literature. Pneumon 2021 Jun;7:1-6.
13. 14. Cut TG, Tudoran C, Lazureanu VE, Marinescu AR, Dumache R, Tudoran M. Spontaneous pneumomediastinum, pneumothorax, pneumopericardium and subcutaneous emphysema-not so uncommon complications in patients with COVID-19 pulmonary infection-a series of cases. J Clin Med 2021 Mar;10(7):1346.
14. 15. Eperjesiova B, Hart E, Shokr M, Sinha P, Ferguson GT. Spontaneous pneumomediastinum/pneumothorax in patients with COVID-19. Cureus 2020 Jul;12(7):e8996.
15. 16. Eurorad - Brought to you by the ESR. Non invasive mechanical ventilation as a rare cause of pulmonary barotrauma in course of COVID 19. 2020 [cited 2022 Jun 8]. Available from: https://www.eurorad.org/case/16891.
16. 17. Rajdev K, Spanel AJ, McMillan S, Lahan S, Boer B, Birge J, et al. Pulmonary barotrauma in COVID-19 patients with ARDS on invasive and non-invasive positive pressure ventilation. J Intensive Care Med 2021 Sep;36(9):1013-1017.
17. 18. Elsaaran H, AlQinai S, AlTarrah D, Abdulrasoul M, Al-Youha S, Almazeedi S, et al. Prevalence and risk factors of barotrauma in Covid-19 patients admitted to an intensive care unit in Kuwait; a retrospective cohort study. Ann Med Surg (Lond) 2021 Mar;63:102141.