COVID-19 ventilator barotrauma management: less is more

Area of Science:

• Thoracic Surgery
• Pulmonology
• Infectious Diseases

Background:

• COVID-19 patients on mechanical ventilation can develop pneumomediastinum and subcutaneous emphysema without pneumothorax (SWAP).
• Prophylactic interventions like chest tubes are common but carry risks of lung injury and viral exposure.
• Data on the incidence and conservative management of SWAP during the pandemic were limited.

Purpose of the Study:

• To evaluate the safety and efficacy of conservative management for SWAP in COVID-19 patients.
• To assess the outcomes of patients with SWAP treated without immediate intervention.
• To provide data on the incidence of SWAP in mechanically ventilated COVID-19 patients.

Main Methods:

• Retrospective review of COVID-19 patients with mediastinal air and SWAP at Mount Sinai Hospital (March 30 - April 10, 2020).
• Patients without pneumothorax were managed conservatively with observation and daily chest X-rays.
• Comparison of outcomes between conservative management and prior prophylactic interventions.

Main Results:

• 29 cases of SWAP identified in 171 intubated COVID-19 patients (17.0%) managed conservatively.
• 41% of patients showed improvement or resolution of SWAP without intervention.
• Two patients progressed to pneumothorax and required chest tube placement without complications.

Conclusions:

• Conservative management is a safe and effective strategy for SWAP in COVID-19 patients.
• This approach minimizes healthcare worker exposure to the virus.
• Chest tube placement should be reserved for cases with a definite, sizable pneumothorax.