PNEUMOMEDIASTINUM IN A CRITICALLY ILL CORONAVIRUS DISEASE 2019 (COVID-19) PATIENT

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) pandemic has displayed heterogeneity in disease manifestations and complications;cardiac, renal, neurological complications and coagulopathy are reported We present a case of COVID-19 with pneumomediastinum CASE PRESENTATION: A 59-year-old male was admitted after a reverse transcriptase polymerase chain reaction (RT-PCR) test- confirmed COVID19 He was confused and was intubated for hypoxia Laboratory investigation showed white blood cells of 2 8x1000/mm3 (normal: 3 4-9 4x1000/ mm3) [differential: 59%(normal: 47-67%) neutrophils and 39% ( normal: 25-45%) lymphocytes], aspartate aminotransferase 1174 IU/l(normal:13-39IU/l), alanine aminotransferase 598 IU/l(normal:7-52IU/l), ferritin > 7500 ng/ml (normal: 20-200 ng/ml), C reactive protein 306 1 mg/l (normal: 0-5 mg/l) and D-dimer 10 mcg/ml (normal: 0-0 50 mcg/ml) Arterial blood gases showed pH 7 14 (normal: 7 35-7 45), PCO2 59 mmHg (normal: 34-46 mmHg) and PO2 54 mmHg (normal: 80-97 mmHg) on 100% oxygen Computed tomography of the chest (CT chest) showed diffuse groundglass opacities Diagnosis of acute respiratory distress syndrome (ARDS) was made On day 5, given low lung compliance (static compliance 13 5 ml/CmH2O), mode was switched to airway pressure release ventilation(APRV) On day 8, subcutaneous emphysema was noted with worsening hemodynamics CT chest showed pneumomediastinum, pneumopericardium and subcutaneous air without pneumothorax APRV was changed to conventional mode and infraclavicular incisions completed Patient‘s status continued to decline;he died on the 13th day of admission DISCUSSION: COVID-19 causes pulmonary involvement ranging from atypical pneumonia to ARDS Few cases of COVID-19-associated pneumomediastinum are reported in the literature Barotrauma from mechanical ventilation accounts for one third cases of pneumomediastinum Although, large tidal volumes are thought to predispose to barotrauma, these associations are related to the severity of lung disease ARDS is most associated and is the only independent risk factor for barotrauma[1] APRV does not demonstrate any difference regarding the onset of barotrauma when compared to conventional modes used in ARDS[2] Different pathological patterns ranging from interstitial lymphocytic infiltrates to organizing pneumonia to diffuse alveolar damage are reported in COVID-19[3] These possibly define the spectrum of COVID-19 and hence the increasing rate of severe complications with worsening injury CONCLUSIONS: COVID-19 patients display diverse complications;pneumomediastinum is an emerging one Further research is needed to study COVID-19 and barotrauma within the clinical and pathological phenotypes of the disease Reference #1: Airway pressures and early barotrauma in patients with acute lung injury and acute respiratory distress Eisner MD, Thompson BT, Schoenfeld D, et al Am J Respir Crit Care Med 165:978-982 2002 Reference #2: Airway pressure release ventilation during acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials Carsetti et al Ann Intensive Care (2019) 9:44 Reference #3: Time to consider histologic pattern of lung injury to treat critically ill patients with COVID-19 infection Marie-Christine Copin, Erika Parmentier, […], and The Lille COVID-19 ICU and Anatomopathology Group Intensive Care Med 2020 Apr 23 :1–3 DISCLOSURES: No relevant relationships by Moses Hayrabedian, source=Web Response No relevant relationships by Faraaz Nayeemuddin, source=Web Response No relevant relationships by Rajagopal Sreedhar, source=Admin input