Massive Pneumomediastinum, Pneumoperitoneum, Subcutaneous Emphysema in SARS-COVID-2 Patient During CPAP Support, Treated by Lateral and Prone Positioning

Introduction Pneumomediastinum (PM) is defined as the presence of free air in the mediastinal cavity. PM may present independently or concurrently with Pneumoperitoneum (PP) and other manifestation of free air. We present a rare Case of massive PM associated with extensive PP and Subcutaneous Emphysema in a SARSCOVID- 2 patient occurred during spontaneous ventilation in CPAP with face-mask. Description A 53-year-old, previously healthy man was admitted to Hospital after 7 days of fever, cough and fatigue, plus worsening dyspnea in the last two days. The body temperature was 39°C, Heart Rate 115 beats/minute and Respiratory Rate (RR) 28 breaths/minute with normal Blood Pressure (125/75 mmHg). The Oxygen Saturation was 86% despite oxygen supplementation by Ventimask 0.50 FiO2. Chest X-ray showed bilateral patchy opacities and he tested positive for SARS-COVID-2 in a nasopharyngeal swab.Support non-invasive ventilation was started using 10 cmH2O CPAP by total face mask. Despite the ventilatory support and increasing FiO2 till 80%, after 3 days the patient worsened, RR was 32 breaths/minute with visible inspiratory effort and attempt to increase tidal volume. Examination of the head and neck revealed crepitus on palpation. On auscultation heartbeat was inaudible, as well as breath sounds at the apex and parasternal, bilaterally. A total-body CT scan showed a massive PM (25 cm transverse and 8.9 cm anterior-posterior) and PP (Fig.1a). The patient was intubated and transferred to the ICU. Tracheoscopy did not show tear or leakage in the tracheal wall. The patient was put on lung protective ventilation with 6 ml/Kg IBW at 100% FiO2 and zero PEEP. The PaO2/FiO2 ratio was below 100. After 3 days, gas exchange and subcutaneous emphysema did not improved, so a further CT scan was performed, showing persistence of the PM. Thoracic surgery consultation suggested to drain the air by parasternal approach, but we noted that during nursing manoeuvres, rolling left and right, the cardiac tone returned audible. Thus, we put the patient on lateral and prone position alternatively. After 48 hours, the PM resolved completely and gas exchange improved (Fig. 1b). Discussion PM could be a complication of COVID disease due to barotrauma and lung frailty. This Case shows that massive PM can occur during CPAP in COVID patient spontaneously breathing, and it can be treated non invasively. PM resolved quickly by lateral and prone positioning. This Case is a reminder that PM should be excluded if acute deterioration occurs in a COVID-19 patient.