Chest X-ray at Emergency Admission and Potential Association with Barotrauma in Mechanically Ventilated Patients: Experience from the Italian Core of the First Pandemic Peak.

Barotrauma occurs in a significant number of patients with COVID-19 interstitial pneumonia undergoing mechanical ventilation. The aim of the current study was to investigate whether the Brixia score (BS) calculated on chest-X-rays acquired at the Emergency Room was associated with barotrauma. We retrospectively evaluated 117 SARS-CoV-2 patients presented to the Emergency Department (ED) and then admitted to the intensive care unit (ICU) for mechanical ventilation between February and April 2020. Subjects were divided into two groups according to the occurrence of barotrauma during their hospitalization. CXRs performed at ED admittance were assessed using the Brixia score. Distribution of barotrauma (pneumomediastinum, pneumothorax, subcutaneous emphysema) was identified in chest CT scans. Thirty-eight subjects (32.5%) developed barotrauma (25 pneumomediastinum, 24 pneumothorax, 24 subcutaneous emphysema). In the barotrauma group we observed higher Brixia score values compared to the non-barotrauma group (mean value 12.18 vs. 9.28), and logistic regression analysis confirmed that Brixia score is associated with the risk of barotrauma. In this work, we also evaluated the relationship between barotrauma and clinical and ventilatory parameters: SOFA score calculated at ICU admittance and number of days of non-invasive ventilation (NIV) prior to intubation emerged as other potential predictors of barotrauma.

Macklin effect on baseline chest CT scan accurately predicts barotrauma in COVID-19 patients.

PURPOSE: To validate the role of Macklin effect on chest CT imaging in predicting subsequent occurrence of pneumomediastinum/pneumothorax (PMD/PNX) in COVID-19 patients. MATERIALS AND METHODS: This is an observational, case-control study. Consecutive COVID-19 patients who underwent chest CT scan at hospital admission during the study time period (October 1st, 2020-April 31st, 2021) were identified. Macklin effect accuracy for prediction of spontaneous barotrauma was measured in terms of sensitivity, specificity, positive (PPV) and negative predictive values (NPV). RESULTS: Overall, 981 COVID-19 patients underwent chest CT scan at hospital arrival during the study time period; 698 patients had radiological signs of interstitial pneumonia and were considered for further evaluation. Among these, Macklin effect was found in 33 (4.7%), including all 32 patients who suffered from barotrauma lately during hospital stay (true positive rate: 96.9%); only 1/33 with Macklin effect did not develop barotrauma (false positive rate: 3.1%). No barotrauma event was recorded in patients without Macklin effect on baseline chest CT scan. Macklin effect yielded a sensitivity of 100% (95% CI: 89.1-100), a specificity of 99.85% (95% CI: 99.2-100), a PPV of 96.7% (95% CI: 80.8-99.5), a NPV of 100% and an accuracy of 99.8% (95% CI: 99.2-100) in predicting PMD/PNX, with a mean advance of 3.2 ± 2.5 days. Moreover, all Macklin-positive patients developed ARDS requiring ICU admission and, in 90.1% of cases, invasive mechanical ventilation. CONCLUSIONS: Macklin effect has high accuracy in predicting PMD/PNX in COVID-19 patients; it is also an excellent predictor of disease severity.

Barotrauma in mechanically ventilated patients with Coronavirus disease 2019: a survey of 38 hospitals in Lombardy, Italy.

BACKGROUND: The aim was to describe the incidence and risk factors of barotrauma in patients with the Coronavirus disease 2019 (COVID-19) on invasive mechanical ventilation, during the outbreak in our region (Lombardy, Italy). METHODS: The study was an electronic survey open from March 27th to May 2nd, 2020. Patients with COVID-19 who developed barotrauma while on invasive mechanical ventilation from 61 hospitals of the COVID-19 Lombardy Intensive Care Unit network were involved. RESULTS: The response rate was 38/61 (62%). The incidence of barotrauma was 145/2041 (7.1%; 95%-CI: 6.1-8.3%). Only a few cases occurred with ventilatory settings that may be considered non-protective such as a plateau airway pressure >35 cmH2O (2/113 [2%]), a driving airway pressure >15 cmH2O (30/113 [27%]), or a tidal volume >8 mL/kg of ideal body weight and a plateau airway pressure >30 cmH2O (12/134 [9%]). CONCLUSIONS: Within the limits of a survey, patients with COVID-19 might be at high risk for barotrauma during invasive (and allegedly lung-protective) mechanical ventilation.

Periorbital emphysema after a wet chamber dive.

Although periorbital emphysema (PE) is commonly associated with orbital fractures, it may develop without any fracture or significant trauma in circumstances such as post-surgery, infection, forceful nose blowing, sneezing, and weight lifting. We report on a healthy military diver who developed PE following a wet chamber dive. A diagnosis of PE secondary to sinus barotrauma was reached. He was treated conservatively without medication and his symptoms recovered completely within 10 days. To the best of our knowledge, only five cases of diving-related PE have been reported in the literature. Analysis of these cases and ours revealed that facial trauma, repeated forceful Valsalva manoeuvres and recent upper respiratory tract infection are probable risk factors for diving-related PE.

Point-of-Care Ultrasound Utility and Potential for High Altitude Crew Recovery Missions.

INTRODUCTION: Flights to high altitude can lead to exposure and unique pathology not seen in normal commercial aviation. METHODS: This paper assesses the potential for point-of-care ultrasound to aid in management and disposition of injured crewmembers from a high altitude incident. This was accomplished through a systematic literature review regarding current diagnostic and therapeutic uses of ultrasound for injuries expected in high altitude free fall and parachuting. RESULTS: While current research supports its utility in diagnostics, therapeutic procedures, and triage decisions, little research has been done regarding its utility in high altitude specific pathology, but its potential has been demonstrated. DISCUSSION: An algorithm was created for use in high altitude missions, in the event of an emergency descent and traumatic landing for an unconscious and hypotensive pilot, to rule out most life threatening causes. Each endpoint includes disposition, allowing concise decision-making.Galdamez LA, Clark JB, Antonsen EL. Point-of-care ultrasound utility and potential for high altitude crew recovery missions. Aerosp Med Hum Perform. 2017; 88(2):128-136.

Middle ear barotrauma causing transient facial nerve paralysis after scuba diving.

Middle ear barotrauma is a well known entity with typical injury occurring when diving or ascending in a commercial jetliner. Patients often present with symptoms of acute onset otalgia, hearing loss and sometimes haemotympanum (with or without tympanic membrane perforation). On rare occasions, facial nerve paralysis can occur when the tympanic segment of the facial nerve is dehiscent within the middle ear. We present a case of spontaneously resolving facial nerve palsy associated with middle ear barotrauma following a brief, shallow dive. Prompt and astute diagnosis leads to proper management with simple myringotomy and can prevent unnecessary testing and other misguided treatments.

[Frontal sinus barotrauma: about a case and review of the literature]. / Barotraumatisme du sinus frontal à propos d'un cas et revue de la littérature.

Sinus barotrauma is the second most frequently reported injury after middle ear barotrauma. The front sinus is the most common site affected. This is a rare and specific pathology. We here report the case of a 26-year-old patient having severe left frontal pain with ipsilateral epistaxis after a dive. CT scan showed left frontal hemosinus. Patient evolution was good after therapy. Frontal sinus barotraumas are accidents related to the variations in environmental pressure. Epistaxis is a sign of serious health condition, CT scanner plays a role in evaluating potential predisposing factors and establishing monitoring procedures. Patient treatment aims to relieve symptoms and to remove predisposing factors. Frontal sinus barotraumas are a rare injury ; orbital and encephalic complications are exceptional. Their treatment coincides with that of their causal pathology.

Magnetic resonance imaging in a guinea pig model of inner ear decompression sickness and barotrauma.

OBJECTIVES/HYPOTHESIS: Scuba diving may cause severe hearing loss and vertigo due to inner ear barotrauma and decompression sickness. These may be difficult to differentiate clinically. Decompression sickness requires costly and potentially dangerous hyperbaric therapy, whereas such treatment may worsen barotrauma. The objective of this study was to assess the potential utility of magnetic resonance imaging to identify and distinguish blood from air in the inner ear, manifestations of barotrauma and decompression sickness, using a guinea pig model. STUDY DESIGN: Prospective animal trial. METHODS: Magnetic resonance of the head was performed at 3 Tesla, pre- and postinjection of 2, 4, or 10 µL of air or blood through the round window into the perilymph. With this model, 2 µL has been shown to cause hearing loss. Images were reviewed by a neuroradiologist blinded to the treatment. RESULTS: All 14 normal ears, five of seven blood- and five of seven air-injected ears, were correctly interpreted. Two blood- and one air-injected ear were interpreted as indeterminate. One air-injected ear was incorrectly interpreted as blood. CONCLUSIONS: Magnetic resonance reliably distinguishes small volumes of air and blood in the guinea pig inner ear. Magnetic resonance should be evaluated for its utility in the diagnosis of inner ear barotrauma and decompression sickness in scuba divers. LEVEL OF EVIDENCE: NA Laryngoscope, 126:2106-2109, 2016.

Periorbital emphysema after dive barotrauma without radiological evidence of paranasal sinus injury.

BACKGROUND: Scuba diving has increased in popularity since its invention in 1943, with over 21 million PADI registered members worldwide. Injuries to the paranasal sinuses caused by barotrauma are the second most common after injury to the middle ear. CASE REPORT: In this paper we present a case of unilateral periorbital surgical emphysema in a 23-yr-old male commercial scuba diver with minimal symptoms following an uneventful 13-ft (4-m) dive. The only symptoms experienced were pain and pressure over the right maxillary sinus and retrorbitally. Imaging with computed tomography showed no fracture of his paranasal sinuses. DISCUSSION: The authors recommend that a high index of suspicion for paranasal sinus barotrauma should be maintained in all patients reporting minor symptoms after diving (even to shallow depths) to facilitate rapid clinical diagnosis and prompt medical management.

Pneumomediastinum or lung damage in breath-hold divers from different mechanisms: a report of three cases.

Normally pulmonary over-inflation is not an issue during breath-hold diving, in contrast to lung squeeze. Compared with compressed air diving, pulmonary barotrauma is rare in breath-hold diving. Several mechanisms can lead to an increase in intrathoracic pressure in breath-hold diving that may cause alveolar rupture. Here we report three cases of pulmonary barotrauma in breath-hold diving. Using high-resolution chest tomography, bullous damage in Case 1, and pneumomediastinum in Cases 2 and 3 were detected. Transient neurological symptoms in Cases 1 and 2 suggested cerebral arterial gas embolism. The mechanisms that caused intrapulmonary overpressure were, respectively, lung packing ('buccal pumping'), considerable effort and straining at depth, and breathing compressed air at depth and ascending without exhaling. All three cases recovered without specific treatment such as recompression.

Widespread subcutaneous emphysema and barotrauma resulting from high pressure gas injection.

Widespread subcutaneous emphysema is an unusual emergency presentation. We present a case of accidental high pressure insufflation, the pathophysiology and subsequent medical management in the acute setting. Such presentations are rare but dramatic and can have important life-threatening consequences that require immediate treatment.

Sphenoid sinus barotrauma after free diving.

We report 2 cases of a 29- and a 37-year-old male patient both having sphenoid sinus barotrauma associated with free diving at about 12-m depth. A unilateral occupation of the sphenoid sinus was revealed in both cases by computed tomography and magnetic resonance imaging examination of the paranasal sinuses.

Barotraumatic oesophageal perforation with bilateral tension pneumothorax.

Barotraumatic oesophageal perforation with bilateral tension pneumothorax is extremely rare and this is a first case reported in the literature. The possibility of the oesophageal perforation due to high-pressure gas flow should be kept in mind and the standard of diagnosis is oesophagography.