COVID-19 and pneumomediastinum in a young man

ABSTRACT

Background: The pathophysiologic mechanisms leading to spontaneous pneumomediastinum (SP) in SARS-CoV-2 patients with severe pneumonia, during mechanical ventilation, are yet not fully elucidated. Case description We report the case of a 21 years old man with positivity for COVID-19 infection. At admission in our department the patient had oxygen saturation of 95% in Venturi mask with FiO2 40%. Chest Computed Tomography (CT) showed extensive areas of increased density of “ground-glass” type with evolution towards crazy paving, involving of 50% of lung parenchyma. On day after admission, the condition of the patient worsened to required mechanical ventilation. Control CT highlighted severe pneumomediastinum and extensive subcutaneous emphysema. The patient was managed with conservative treatments and with high flow nasal cannula (HFNC). A week later chest CT showed almost complete resolution of subcutaneous emphysema and pneumomediastinum. The improvement of the blood gas parameters allowed weaning from the HFNC and suspension of oxygen therapy. Conclusions: Although the mechanism of the SP still remains unknown, the presumed cause is the combination of diffuse alveolar injuries due to SARS-CoV-2 and an increase intra-alveolar pressure with barotrauma due to coughing, Valsalva maneuvers or mechanical ventilation. Presumably in SARS-CoV-2 related SP lung frailty, due to crazy paving pattern, impairs compliance e reduces lung tolerance to pressure variations. HFNC could be a safe ventilatory support for critical COVID-19 pneumonia together antitussive and sedatives drugs.