Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate-Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital

Nardi Tetaj; Gabriele Garotto; Fabrizio Albarello; Annelisa Mastrobattista; Micaela Maritti; Giulia Valeria Stazi; Maria Cristina Marini; Ilaria Caravella; Manuela Macchione; Giada De Angelis; Donatella Busso; Rachele Di Lorenzo; Silvana Scarcia; Anna Farina; Daniele Centanni; Joel Vargas; Martina Savino; Alessandro Carucci; Andrea Antinori; Fabrizio Palmieri; Gianpiero D'Offizi; Stefania Ianniello; Fabrizio Taglietti; Paolo Campioni; Francesco Vaia; Emanuele Nicastri; Enrico Girardi; Luisa Marchioni; Icu Covid-Study Group

doi:10.3390/jcm10235608

Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate-Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital

J Clin Med. 2021 Nov 29;10(23):5608. doi: 10.3390/jcm10235608.

Authors

Nardi Tetaj¹, Gabriele Garotto¹, Fabrizio Albarello², Annelisa Mastrobattista³, Micaela Maritti¹, Giulia Valeria Stazi¹, Maria Cristina Marini¹, Ilaria Caravella¹, Manuela Macchione¹, Giada De Angelis¹, Donatella Busso¹, Rachele Di Lorenzo¹, Silvana Scarcia¹, Anna Farina¹, Daniele Centanni⁴, Joel Vargas⁵, Martina Savino⁵, Alessandro Carucci¹, Andrea Antinori⁴, Fabrizio Palmieri³, Gianpiero D'Offizi⁴, Stefania Ianniello², Fabrizio Taglietti⁴, Paolo Campioni², Francesco Vaia⁶, Emanuele Nicastri⁴, Enrico Girardi⁷, Luisa Marchioni¹, Icu Covid-Study Group

Affiliations

¹ UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy.
² Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy.
³ Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy.
⁴ Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy.
⁵ Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy.
⁶ Health Direction, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy.
⁷ Scientific Direction, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy.

Abstract

(1) Background: COVID-19 is a novel cause of acute respiratory distress syndrome (ARDS). Indeed, with the increase of ARDS cases due to the COVID-19 pandemic, there has also been an increase in the incidence of cases with pneumothorax (PNX) and pneumomediastinum (PNM). However, the incidence and the predictors of PNX/PMN in these patients are currently unclear and even conflicting. (2) Methods: The present observational study analyzed the incidence of barotrauma (PNX/PNM) in COVID-19 patients with moderate-severe ARDS hospitalized in a year of the pandemic, also focusing on the three waves occurring during the year, and treated with positive-pressure ventilation (PPV). We collected demographic and clinical data. (3) Results: During this period, 40 patients developed PNX/PNM. The overall incidence of barotrauma in all COVID-19 patients hospitalized in a year was 1.6%, and in those with moderate-severe ARDS in PPV was 7.2% and 3.8 events per 1000 positive-pressure ventilator days. The incidence of barotrauma in moderate-severe ARDS COVID-19 patients during the three waves was 7.8%, 7.4%, and 8.7%, respectively. Treatment with noninvasive respiratory support alone was associated with an incidence of barotrauma of 9.1% and 2.6 events per 1000 noninvasive ventilator days, of which 95% were admitted to the ICU after the event, due to a worsening of respiratory parameters. The incidence of barotrauma of ICU COVID-19 patients in invasive ventilation over a year was 5.8% and 2.7 events per 1000 invasive ventilator days. There was no significant difference in demographics and clinical features between the barotrauma and non-barotrauma group. The mortality was higher in the barotrauma group (17 patients died, 47.2%) than in the non-barotrauma group (170 patients died, 37%), although this difference was not statistically significant (p = 0.429). (4) Conclusions: The incidence of PNX/PNM in moderate-severe ARDS COVID-19 patients did not differ significantly between the three waves over a year, and does not appear to be very different from that in ARDS patients in the pre-COVID era. The barotrauma does not appear to significantly increase mortality in COVID-19 patients with moderate-severe ARDS if protective ventilation strategies are applied. Attention should be paid to the risk of barotrauma in COVID-19 patients in noninvasive ventilation because the event increases the probability of admission to the intensive care unit (ICU) and intubation.

Keywords: COVID-19; COVID-19 waves; barotrauma; intensive care unit; invasive mechanical ventilation; non-invasive ventilation; pneumomediastinum; pneumothorax; subcutaneous emphysema.