Pulmonary barotrauma resulting from mechanical ventilation in 2 patients with a diagnosis of covid-19 pneumonia

Abstract

Objective: Background: Case Reports: Conclusions: Unusual clinical course Invasive mechanical ventilation can cause pulmonary barotrauma due to elevated transpulmonary pressure and alveolar rupture. A significant proportion of COVID-19 patients with acute respiratory distress syndrome (ARDS) will require mechanical ventilation. We present 2 interesting cases that demonstrate the possibility of COVID-19-associated ARDS manifesting with pulmonary barotrauma at acceptable ventilatory pressures. The first patient was a 71-year-old man who was intubated and placed on mechanical ventilation due to hy-poxemic respiratory failure from SARS-CoV-2 infection. His partial pressure of O2 to fraction of inspired oxy-gen ratio (PaO2/FiO2) was 156. He developed subcutaneous emphysema (SE) and pneumomediastinum on day 5 of mechanical ventilation at ventilatory settings of positive end-expiratory pressure (PEEP) ≤15 cmH2 O, plateau pressure (Pplat) ≤25 cmH2 O and pulmonary inspiratory pressure (PIP) ≤30 cmH2 O. He was managed with ‘blow-hole’ incisions, with subsequent clinical resolution of subcutaneous emphysema. The second patient was a 58-year-old woman who was also mechanically ventilated due to hypoxemic respiratory failure from COVID-19, with PaO2/FiO2 of 81. She developed extensive SE with pneumomediastinum and pneumo-thorax while on mechanical ventilation settings PEEP 13 cmH2 O and PIP 28 cmH2 O, Pplat 18 cmH2 O, and FiO2 90%. SE was managed with blow-hole incisions and pneumothorax with chest tube. Clinicians should be aware of pulmonary barotrauma as a possible complication of COVID-19 pulmonary dis-ease, even at low ventilatory pressures.