LAUSR

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Pneumomediastinum is a rare entity in viral pneumonias. Only about 1% of patients in the ARDSNet trials developed pneumomediastinum as an early complication in the first four days of mechanical ventilation. With SARS-CoV-1, there were reports of late development of barotrauma complications, but there are very few case reports of pneumomediastinum in the current pandemic. We present a case of a tension pneumomediastinum and pneumoperitoneum as a complication of SARS-CoV-2. CASE PRESENTATION: An 86-year-old female was hospitalized for respiratory failure secondary to COVID-19. She was treated and discharged to a nursing facility requiring supplemental oxygen. Two days later, she developed worsening respiratory failure requiring intubation and mechanical ventilation with pressure-regulated volume control mode. CT imaging on admission revealed only viral pneumonia changes. Despite open lung ventilation strategy, she required plateau pressures of 32cmH20 to maintain adequate gas exchange. Hospital day 10, her respiratory failure worsened with increased plateau pressures of 40cmH20 despite no changes in her ventilator settings. She required paralysis and proning at that time with no changes on chest x-ray and no abnormalities were appreciated on exam other than developing ventilator dyssynchrony. She deteriorated further on hospital day 15 with development of shock and chest x-ray demonstrating possible free air in the mediastinum and abdomen. CT confirmed massive amounts of intraperitoneal, retroperitoneal, and mediastinal air without pneumothorax. Given her poor prognosis, she was transitioned to comfort measures and expired. DISCUSSION: COVID-19-related pneumomediastinum is thought to develop from diffuse alveolar injury and fibrosis leading to increased alveolar pressures, which ultimately rupture. Barotrauma from mechanical ventilation exacerbates this. Patients may be asymptomatic or they may have signs of tachycardia, tachypnea, and/or subcutaneous emphysema with upper chest and neck swelling. Tension pneumomediastinum is an exceedingly rare but life threatening development in critically ill patients. The development of pneumomediastinum related to SARS-CoV-2 seems to occur later in the disease course when compared to ARDSNet trials, however this may be similar to reports in SARS-CoV-1. CONCLUSIONS: Despite the rare occurrence of pneumomediastinum in viral pneumonia, providers should be aware of this potential late complication in SARS-CoV-2 and take measures for prevention and early recognition. Without adjusting treatment, tension pneumomediastinum may develop and lead to a significant increase in mortality. REFERENCE #1: Chu CM, et al. Spontaneous pneumomediastinum in patients with severe acute respiratory syndrome. European Respiratory Journal 2004 23: 802-804;DOI: 10.1183/09031936.04.00096404 REFERENCE #2: Mart M, et al. Pneumomediastinum in Acute Respiratory Distress Syndrome from COVID-19. Am J Respir Crit Care Med Vol 203, Iss 2, pp 237–238. DOI: 10.1164/rccm.202008-3376IM REFERENCE #3: Clancy DJ, et al. Tension pneumomediastinum: a literal form of chest tightness. J Intensive Care Soc 2017;18(1): 52–56. DISCLOSURES: No relevant relationships by Rayan Ihle, source=Web Response No relevant relationships by Mark Radow, source=Web Response