COVID-19 associated spontaneous barotrauma: a literature review

Reports of spontaneous pneumothorax and pneumomediastinum as a complication of coronavirus disease (COVID-19) have been increasing. COVID-19 causes inflammatory disease mainly affecting the respiratory system. Severity varies from asymptomatic pulmonary findings on imaging to acute respiratory distress syndrome along with pleural effusions, consolidations and spontaneous pneumomediastinum and pneumothorax. The aim of this paper was to review the literature to explore the association between pneumomediastinum/pneumothorax and COVID-19 respiratory disease, both in patients on ventilators and without ventilators, on a spontaneous basis. To this end, we conducted a comprehensive online literature search using PubMed for articles published with the key words of ‘spontaneous pneumothorax’, ‘pneumomediastinum’ and ‘COVID-19’. Further references were obtained through cross-referencing the bibliographies cited in each publication. We found that spontaneous barotrauma is one of the complications associated with COVID-19 infection and has been observed in patients with and without mechanical ventilation. The process of pneumomediastinum and pneumothorax development is not well understood, especially in patients without underlying lung disease or on mechanical ventilation. We identified various factors that predispose to barotrauma. First, the direct infection of the Type I and Type II pneumocytes by the virus. Second, the pressure gradient between the alveoli and the pulmonary interstitium. Finally, barotrauma can occur secondary to the severe inflammatory response from the COVID-19-related cytokine storm. These conditions are all associated with severe alveolar damage and rupture of the alveolar wall that can produce pneumomediastinum and pneumothorax, both in mechanically ventilated patients and non-ventilated patients. COVID-19 is associated complications result in prolonged mechanical ventilation and length of stay, as well as overall increase in morbidity and mortality. Spontaneous pneumothorax and pneumomediastinum are two serious complications. Education regarding the adjustment of ventilation settlings in the ventilator-dependent COVID-19 patient may perhaps offset the iatrogenic component of barotrauma seen in some such patients.