Pulmonary barotrauma in mechanically ventilated coronavirus disease 2019 patients: A case series

Background: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may result in hypoxic respiratory failure necessitating mechanical ventilation. Barotrauma is a well-documented complication of mechanical ventilation. Objective: To describe the presentation, characteristics, and management of mechanically ventilated patients with COVID-19 who developed barotrauma. Methods: Retrospective case series study of 13 adult, mechanically ventilated, laboratory-confirmed COVID-19 positive patients admitted between 3/15/2020 and 4/14/2020 to a community hospital in New York City. Patient demographics, clinical course, ventilatory parameters, and radiographic results were obtained from electronic medical records. Barotrauma was defined as pneumomediastinum, subcutaneous emphysema, and or pneumothorax on chest X-ray. Descriptive analyses and Mann-Whitney U test were performed, where appropriate. Results: Of the 574 COVID-19 positive patients, 139 (24.2%) needed mechanical ventilation and 13 (9.4%) of those developed barotrauma. Majority of patients were Black race (92.3%), older than age 65 (56.8%), male (69.2%), and had comorbidities (76.9%). Most common presenting symptoms were cough (84.6%) and dyspnea (76.9%). Barotrauma presentations included 3/13 pneumothoraces and pneumomediastinum, 12/13 pneumomediastinum and subcutaneous emphysema, and 1/13 pneumothorax alone. The average days on ventilator was 3.4, average positive expiratory-end pressure 15.5 cmH2O, dynamic compliance 33.8 mL/cmH2O, and P/F ratio 165. Interventions were 4/13 chest tubes and 2/13 pigtail catheters. Conclusions: Barotrauma is a common complication of mechanical ventilation of COVID-19 patients. Despite high ventilatory pressures, tension pneumothorax is rare and barotrauma could potentially be managed conservatively. Further studies are needed to evaluate the indication and outcome of thoracostomies and conservative management.