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Published on: December 19, 2020
Pneumomediastinum in COVID-19 disease: Outcomes and relation to the Macklin effect
João Brito1, Paulo Gregório1, Alessandro Mariani1
1Division of Thoracic Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Aim:
Pneumomediastinum (PM) is associated with several etiologies and mechanisms. Although it has been described more than 100 years ago, the literature is limited to small retrospective studies. This study aimed to follow patients with coronavirus disease (COVID-19) that developed PM during hospitalization and describe their clinical and radiological evolution.
Methods:
A prospective cohort was developed with patients with PM, excluding those with aerodigestive trauma, inside a hospital COVID-19 dedicated hospital. Clinical variables including onset of symptoms, hemodynamic instability, associated complications, the need of interventions, and disease course were all recorded. Also, radiological findings such as the presence of the Macklin effect, extension of lung involvement by COVID-19, and characteristics of the PM were analyzed.
Results:
Twenty-one patients with non-traumatic PM were followed, resulting in an overall incidence of 0.5% during the study period. Seven (33%) patients had associated pneumothorax and malignant/tension PM was observed in three (14%) cases. The Macklin effect could be found in 11 patients (52%) and the majority of them had more than 50% of lung involvement due to COVID-19. The mortality rate was 49%; however, no deaths were directly related to the PM.
Conclusions:
PM incidence is probably increased in the severe acute respiratory syndrome caused by COVID-19, especially in those with greater involvement of the lungs, and the Macklin effect may be an important underlying mechanism of this complication. Usually, PM has a benign course, but complications like tension/malignant PM may occur requiring prompt detection and intervention.
Insights
Pneumomediastinum (PM) incidence increased in COVID-19 patients, particularly those with extensive lung involvement. The Macklin effect is a key mechanism, though PM usually has a benign course, requiring vigilance for potential complications.
Area of Science:
- Pulmonology
- Infectious Diseases
- Radiology
Background:
- Pneumomediastinum (PM) is a rare condition with limited literature, primarily from small retrospective studies.
- Understanding PM in the context of COVID-19 is crucial due to its potential impact on respiratory function.
Purpose of the Study:
- To prospectively investigate the incidence, clinical course, and radiological findings of pneumomediastinum in hospitalized COVID-19 patients.
- To identify potential underlying mechanisms and associated complications of PM in this population.
Main Methods:
- A prospective cohort study included 21 non-traumatic pneumomediastinum patients admitted to a COVID-19 dedicated hospital.
- Clinical data (symptoms, instability, interventions, outcomes) and radiological findings (Macklin effect, lung involvement) were analyzed.
Main Results:
- The incidence of PM was 0.5% among COVID-19 patients.
- Pneumothorax occurred in 33% of cases, with 14% developing tension/malignant PM.
- The Macklin effect was present in 52% of patients, often associated with >50% lung involvement; overall mortality was 49% (unrelated to PM).
Conclusions:
- Pneumomediastinum incidence appears elevated in severe COVID-19, especially with significant lung compromise.
- The Macklin effect is a likely mechanism for PM in COVID-19.
- While typically benign, PM can develop serious complications requiring prompt management.
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