LAUSR

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: SARS-CoV-2 (COVID-19) is a rapidly spreading virus that has resulted in a pandemic. Individuals impacted have varying symptoms and disease courses, ranging from asymptomatic carriers to severe respiratory illness. Pneumomediastinum, a rare complication of COVID-19 (where air is present in the mediastinum with or without pneumothorax) is presented here. CASE PRESENTATION: Our case is that of a 59-year-old man who presented to the emergency department with complaints of fever and chills for five days. His past medical history included hypertension, type 2 diabetes mellitus and hyperlipidemia. He endorsed associated dry cough, decreased appetite and shortness of breath. He denied recent travel or exposure to COVID-19. Initially the patient was hemodynamically stable, but hypoxic with oxygen saturation of 82%, requiring 4L nasal cannula (NC) – with improvement to 93-95%. Chest imaging revealed low lung volumes and patchy bilateral opacities. COVID-19 PCR was positive. He was admitted to the medical floor with acute COVID-19 pneumonia. He was treated with dexamethasone and remdesivir, and was encouraged to self-prone. Due to worsening hypoxia, he required a non-rebreather mask. Daily chest x rays were obtained, and on hospital day seven, imaging revealed air around the neck, suggesting pneumomediastinum without pneumothorax. CT chest and neck showed significant air dissecting up from the superior mediastinum, extending through the neck soft tissues bilaterally, confirming acute pneumomediastinum. With further pulmonary decompensation and respiratory failure, he required intubation and mechanical ventilation. A low PEEP strategy was employed to prevent worsening pneumomediastinum. In the subsequent week, although his pneumomediastinum resolved, the patient unfortunately developed ARDS and passed away. DISCUSSION: This presentation of acute pneumomediastinum in the setting of COVID-19 is an uncommon complication of the viral illness. Diffuse alveolar damage and/or complication of mechanical ventilation have been speculated to be possible causes. Pneumomediastinum is typically a benign diagnosis, but can sometimes progress to malignant mediastinum, where air compresses the trachea or venous return, which can in turn present as cardiac tamponade. In these cases, chest tube, VATS or thoracotomy may be indicated.1 CONCLUSIONS: Cases of pneumomediastinum in patients infected with COVID-19 are limited, hence its impact on worsening illness or outcome cannot be determined. Recommendations continue to focus on close monitoring with daily chest imaging. Should intubation be required, it is recommended to maintain a needle at bedside for needle thoracostomy in the event acute pneumothorax occurs.2 A low tidal volume, low PEEP strategy is also encouraged to mitigate risk of further barotrauma.3 Early paralysis may be beneficial to prevent coughing or ventilator dyssynchrony. REFERENCE #1: Kouritas VK, Papagiannopoulos K, Lazaridis G, et al. Pneumomediastinum. J Thorac Dis. 2015;7(Suppl 1):S44-S49. doi:10.3978/j.issn.2072-1439.2015.01.11 REFERENCE #2: Mousa S, Edriss H. Pneumomediastinum secondary to invasive and non-invasive mechanical ventilation. The Southwest Respiratory and Critical Care Chronicles. 2019;7(27), 36-42. https://doi.org/10.12746/swrccc.v7i27.524 REFERENCE #3: Wali A, Rizzo V, Bille A, Routledge T, Chambers A. Pneumomediastinum following intubation in COVID-19 patients: a case series. Anaesthesia. 2020;75: 1076-1081. https://doi.org/10.1111/anae.15113 DISCLOSURES: No relevant relationships by James McGee, source=Web Response No relevant relationships by Cilian White, source=Web Response No relevant relationships by Momina Zaman, source=Web Response