Subcutaneous and mediastinal emphysema, uncommon complications of COVID-19 ARDS: a case series

Coronavirus disease 2019 (COVID-19) adult respiratory distress syndrome (C-ARDS) has led to ventilator related complications such as ventilator associated events (VAE), venous thromboembolic events (VTE), barotrauma, and ultimately profound diffuse pulmonary fibrosis. Barotrauma is one such complication, with reports of spontaneous pneumothorax (PTX) and pneumomediastinum. We present a case series of four patients with severe C-ARDS, complicated by subcutaneous emphysema and mediastinal emphysema with and without pneumothroracies, which required supportive care, except one patient with PTX. Of the four patients only one patient was discharged alive. C-ARDS can induce lung injury, resulting in subcutaneous and mediastinal emphysema, which may not represent a PTX as etiology. The exact mechanism of subcutaneous emphysema and mediastinal emphysema without pneumothoracies in the setting of severe C-ARDS has not been clearly elucidated. Two plausible mechanisms may be related to the “Macklin effect” vs. type I and II pneumocyte breakdown when infected by COVID-19. Strategies used to minimize worsening of subcutaneous and mediastinal emphysema with and without pneumothoracies, may be to minimize positive end-expiratory pressure (PEEP), continue to maintain a lung protective strategy (LPS), while utilizing a higher fraction of inspired oxygen (FiO2) concentration. In the majority of cases, supportive care is usually required, unless PTX presents or tension pneumomediastinum develops, at which time treatment with a thoracostomy tube placement may be necessary or cardiothoracic surgery consultation may be warranted, to perform “gills” procedure. © Journal of Emergency and Critical Care Medicine. All rights reserved.