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.

Incidence of dental barotrauma and temporomandibular joint problems of divers in Turkey.

Introduction: In this study, we aimed to examine dental barotrauma and temporomandibular joint (TMJ) complaints in a large group of divers. Methods: This survey study included scuba divers older than 18. The questionnaire contained 25 questions about the demographic characteristics of divers, dental health behaviors, and diving-related dental, sinus and/or temporomandibular joint pain. Results: The study group consisted of 287 instructors, recreational and commercial divers (mean age 38.96 years) (79.1% males). A total of 46% of divers reported a frequency of tooth brushing less than twice a day; 28% never receive a routine dental examination; 22.6% experienced dental pain after and/or during diving, mostly in the upper posterior teeth (40%); 17% required dental treatment; 77% of these cases are restoration fracture. TMJ symptoms after diving were statistically significantly higher in women (p=0.04). Jaw and masticatory muscle pain in the morning (p≺0.001) limitation of mouth opening (p=0.04) and joint sounds in daily life (p≺0.001) were recorded as exacerbated after diving; the results were found to be statistically significant. Conclusion: In our study, the localization of barodontalgia was consistent with the distribution of caries and restored tooth areas in the literature. Dive-related TMJ pain was also more common in those with pre-dive problems such as bruxism and joint noise. Our results are important to remind us of the necessity of preventive dentistry practices and early diagnosis of problems in divers. Divers should take personal precautions, such as brushing their teeth twice a day and avoiding the need for urgent treatment. The use of a personalized mouthpiece is also recommended for divers to prevent dive-related temporomandibular joint diseases.

Barotrauma in COVID-19 acute respiratory distress syndrome: retrospective analysis of the COVADIS prospective multicenter observational database.

BACKGROUND: Despite evidence suggesting a higher risk of barotrauma during COVID-19-related acute respiratory distress syndrome (ARDS) compared to ARDS due to other causes, data are limited about possible associations with patient characteristics, ventilation strategy, and survival. METHODS: This prospective observational multicenter study included consecutive patients with moderate-to-severe COVID-19 ARDS requiring invasive mechanical ventilation and managed at any of 12 centers in France and Belgium between March and December 2020. The primary objective was to determine whether barotrauma was associated with ICU mortality (censored on day 90), and the secondary objective was to identify factors associated with barotrauma. RESULTS: Of 586 patients, 48 (8.2%) experienced barotrauma, including 35 with pneumothorax, 23 with pneumomediastinum, 1 with pneumoperitoneum, and 6 with subcutaneous emphysema. Median time from mechanical ventilation initiation to barotrauma detection was 3 [0-17] days. All patients received protective ventilation and nearly half (23/48) were in volume-controlled mode. Barotrauma was associated with higher hospital mortality (P < 0.001) even after adjustment on age, sex, comorbidities, PaO2/FiO2 at intubation, plateau pressure at intubation, and center (P < 0.05). The group with barotrauma had a lower mean body mass index (28.6 ± 5.8 vs. 30.3 ± 5.9, P = 0.03) and a higher proportion of patients given corticosteroids (87.5% vs. 63.4%, P = 0.001). CONCLUSION: Barotrauma during mechanical ventilation for COVID-19 ARDS was associated with higher hospital mortality.

Incidence, outcomes and risk factors of barotrauma in veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome.

BACKGROUND: Although acute respiratory distress syndrome (ARDS) patients are provided a lung rest strategy during extracorporeal membrane oxygenation (ECMO) treatment, the exact conditions of barotrauma is unclear. Therefore, we analyzed the epidemiology and risk factors for barotrauma in ARDS patients using ECMO in a single, large ECMO center in China. METHODS: A retrospective analysis was performed on 127 patients with ARDS received veno-venous (VV) ECMO who met the Berlin definition. The epidemiology and risk factors for barotrauma during ECMO were analyzed. RESULTS: Among 127 patients with ARDS treated with ECMO, barotrauma occurred in 24 (18.9%) during ECMO and 9 (7.1%) after ECMO decannulation, mainly in the late stage of ARDS (75%) and ≥8 days during ECMO (54.2%). Univariate and multivariate analyses showed that younger ARDS patients (OR = 0.953, 95%CI 0.923-0.983, p = 0.003) and those with pneumocystis jirovecii pneumonia (PJP) (OR = 3.15, 95%CI 1.070-9.271, p = 0.037), elevated body temperature after establishing ECMO (OR = 2.997, 95%CI 1.325-6.779, p = 0.008) and low platelet count after establishing ECMO (OR = 0.985, 95%CI 0.972-0.998, p = 0.02) had an increased risk of barotrauma during ECMO. There was no difference in ventilator parameters between patients with and without barotrauma. Barotrauma during ECMO was mainly related to the etiology of the disease and disease state. CONCLUSION: There is a high incidence of barotrauma in ARDS patients during ECMO, even after ECMO decannulation. Young age, PJP, elevated body temperature and low platelet count after establishing ECMO are risk factors of barotrauma, and those patients should be closely monitored by imaging, especially in the late stage of ARDS.

Clinical use of Macklin-like radiological sign (Macklin effect): A systematic review.

INTRODUCTION: Recent studies suggested that Macklin sign is a predictor of barotrauma in patients with acute respiratory distress syndrome (ARDS). We performed a systematic review to further characterize the clinical role of Macklin. METHODS: PubMed, Scopus, Cochrane Central Register and Embase were searched for studies reporting data on Macklin. Studies without data on chest CT, pediatric studies, non-human and cadaver studies, case reports and series including <5 patients were excluded. The primary objective was to assess the number of patients with Macklin sign and barotrauma. Secondary objectives were: occurrence of Macklin in different populations, clinical use of Macklin, prognostic impact of Macklin. RESULTS: Seven studies enrolling 979 patients were included. Macklin was present in 4-22% of COVID-19 patients. It was associated with barotrauma in 124/138 (89.8%) of cases. Macklin sign preceded barotrauma in 65/69 cases (94.2%) 3-8 days in advance. Four studies used Macklin as pathophysiological explanation for barotrauma, two studies as a predictor of barotrauma and one as a decision-making tool. Two studies suggested that Macklin is a strong predictor of barotrauma in ARDS patients and one study used Macklin sign to candidate high-risk ARDS patients to awake extracorporeal membrane oxygenation (ECMO). A possible correlation between Macklin and worse prognosis was suggested in two studies on COVID-19 and blunt chest trauma. CONCLUSIONS: Increasing evidence suggests that Macklin sign anticipate barotrauma in patients with ARDS and there are initial reports on use of Macklin as a decision-making tool. Further studies investigating the role of Macklin sign in ARDS are justified.

A review of 149 Divers Alert Network emergency call records involving diving minors.

INTRODUCTION: Minors have been scuba diving for decades, and while the initial concerns about potential long-term complications related to bone development appear to be unfounded, the incidence of scuba diving injuries among them has been poorly studied. METHODS: We reviewed 10,159 cases recorded in the DAN Medical Services call centre database from 2014 through 2016 and identified 149 cases of injured divers younger than 18 years. Records were analysed for case categorisation on the most common dive injuries. Information about demographics, level of training, risk factors, and relevant behavioural aspects were collected when available. RESULTS: While the most common reason for the call was to rule out decompression sickness, the majority of cases pertained to ear and sinus issues. However, 15% of the dive-related injuries involving minors had a final diagnosis of pulmonary barotrauma (PBt). While no reliable data is available on the incidence of PBt in adult divers, the authors' impression based on personal experience suggests that the number of cases of PBt in minors trends higher than in the general diving population. The narratives on some relevant records describe unmanageable levels of anxiety leading to panic. CONCLUSIONS: Based on the results and narratives on these cases, it is reasonable to infer that psychological immaturity, suboptimal management of adverse situations, and inadequate supervision might have led to severe injuries among these minor divers.

The Macklin effect closely correlates with pneumomediastinum in acutely ill intubated patients with COVID-19 infection.

PURPOSE: Patients with COVID-19 infection are frequently found to have pulmonary barotrauma. Recent work has identified the Macklin effect as a radiographic sign that often occurs in patients with COVID-19 and may correlate with barotrauma. METHODS: We evaluated chest CT scans in COVID-19 positive mechanically ventilated patients for the Macklin effect and any type of pulmonary barotrauma. Patient charts were reviewed to identify demographic and clinical characteristics. RESULTS: The Macklin effect on chest CT scan was identified in a total of 10/75 (13.3%) COVID-19 positive mechanically ventilated patients; 9 developed barotrauma. Patients with the Macklin effect on chest CT scan had a 90% rate of pneumomediastinum (p < 0.001) and a trend toward a higher rate of pneumothorax (60%, p = 0.09). Pneumothorax was most frequently omolateral to the site of the Macklin effect (83.3%). CONCLUSION: The Macklin effect may be a strong radiographic biomarker for pulmonary barotrauma, most strongly correlating with pneumomediastinum. Studies in ARDS patients without COVID-19 are needed to validate this sign in a broader population. If validated in a broad population, future critical care treatment algorithms may include the Macklin sign for clinical decision making and prognostication.

High incidence of barotrauma in patients admitted with COVID-19 to ICU and associated mortality in rural Appalachia: An observational study.

OBJECTIVES: To assess the incidence of barotrauma and its impact on mortality in COVID-19 patients admitted to ICU. DESIGN: Single-center retrospective study of consecutive COVID-19 patients admitted to a rural tertiary-care ICU. The primary outcomes were incidence of barotrauma in COVID-19 patients and all-cause 30-day mortality. Secondary outcomes were the length of stay (LOS) in the hospital and ICU. Kaplan-Meier method and log-rank test were used in the survival data analysis. SETTING: Medical ICU, West Virginia University Hospital (WVUH), USA. PATIENTS: All adult patients were admitted to the ICU for acute hypoxic respiratory failure due to coronavirus disease 2019 between September 1, 2020, and December 31, 2020. Historical controls were ARDS patients admitted pre-COVID. INTERVENTION: Not applicable. MEASUREMENTS AND MAIN RESULTS: One hundred and sixty-five consecutive patients with COVID-19 were admitted to the ICU during the defined period, compared to 39 historical non-COVID controls. The overall incidence of barotrauma in COVID-19 patients was 37/165 (22.4%) compared to 4/39 (10.3%) in the control group. Patients with COVID-19 and barotrauma had a significantly worse survival (HR = 1.56, p = 0.047) compared to controls. In those requiring invasive mechanical ventilation, the COVID group also had significantly higher rates of barotrauma (OR 3.1, p = 0.03) and worse all-cause mortality (OR 2.21, p = 0.018). COVID-19 with barotrauma had significantly higher LOS in the ICU and the hospital. CONCLUSIONS: Our data on critically ill COVID-19 patients admitted to the ICU shows a high incidence of barotrauma and mortality compared to the controls. Additionally, we report a high incidence of barotrauma even in non-ventilated ICU patients.

Ventilatory associated barotrauma in COVID-19 patients: A multicenter observational case control study (COVI-MIX-study).

BACKGROUND: The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication. METHODS: This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death. RESULTS: We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001). CONCLUSIONS: C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality. TRIAL REGISTRATION: this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021).

Functional assessment of military aircrew applicants in a hypobaric chamber.

BACKGROUND: Aircrew are exposed to environmental pressure changes. In the Republic of Singapore Air Force (RSAF), applicants assessed to be at intermediate risk of otic barotrauma undergo a hypobaric chamber assessment ["trial of chamber" (TOC)] to functionally evaluate their suitability for military aircrew vocations. AIMS: To identify factors associated with TOC failure among applicants with otorhinolaryngological conditions. METHODS: All applicants to RSAF aircrew vocations who were assessed to be at intermediate risk of otic barotrauma over a 3-yr period were identified using the RSAF Aeromedical Centre's electronic database. Their medical records, as well as the TOC assessment records of the subset of applicants who underwent TOC, were reviewed for demographic data, clinical findings, and TOC outcomes. RESULTS: Of the 483 identified applicants, 374 (77%) had abnormal otoscopic findings, 103 (21%) had rhinitis symptoms, and 6 (1%) had previous ENT surgery. 123 (25%) underwent TOC, of which 20 (16%) failed. Holding other predictor variables constant, the odds of TOC failure increased by 0.79 per unit decrease in BMI (95% CI 0.63-0.99), and the odds of TOC failure increased by 0.93 per kg decrease in body weight (95% CI 0.87-1.00). An abnormal tympanogram was not a statistically significant predictor of TOC failure (OR 1.96, 95% CI 0.59-6.42). Of the 47 applicants who passed TOC and were eventually recruited, none subsequently developed otic barotrauma (mean follow-up, 3.3 yr ± 1.5 yr). CONCLUSIONS: Applicants with lower weight and BMI are more likely to develop otic barotrauma with environmental pressure change. Tympanometry cannot be reliably used to identify applicants who would more likely pass TOC.

Middle Ear Barotrauma among Licensed Para-pilots of a Metropolitan City: A Descriptive Cross-sectional Study.

Introduction: Middle ear barotrauma is a tissue injury to the ear secondary to inadequate pressure equalisation between the middle ear and the external environment. Paragliding, though an exciting sport, has its own risks and hazards. Para-pilots experience a variety of ear-related symptoms due to pressure discrepancies between the middle ear and ambient air. Middle ear barotrauma amongst para-pilots is a common yet neglected problem. The aim of this study was to find the prevalence of middle ear barotrauma among licensed para-pilots of a metropolitan city. Methods: A descriptive cross-sectional study was conducted amongst para-pilots practising in different paragliding companies in a metropolitan city. The study was conducted from 10th October, 2021 to 22nd October, 2021 after getting ethical approval from the Institutional Review Committee (Reference number: 0410202109/2021). A sample size of 76 participants was taken using convenience sampling technique. Data was collected from participants after performing an otoscope examination. The data were entered into Microsoft Excel version 2016 and analysed using the Statistical Package for the Social Science Version 22.0. Point estimate at a 95% Confidence Interval was calculated along with frequency and proportion for binary data and mean and standard deviation for continuous data. Results: Out of 76 participants, the prevalence of middle ear barotrauma was 10 (13.2%) (5.58-20.81 at 95% Confidence Interval). Conclusions: The prevalence of middle ear barotrauma was similar to other studies done in similar settings. Keywords: barotrauma; eustachian tube; Nepal; pilots.

Venovenous Extracorporeal Membrane Oxygenation in Awake Non-Intubated Patients With COVID-19 ARDS at High Risk for Barotrauma.

OBJECTIVES: To assess the efficacy of an awake venovenous extracorporeal membrane oxygenation (VV-ECMO) management strategy in preventing clinically relevant barotrauma in patients with coronavirus disease 2019 (COVID-19) with severe acute respiratory distress syndrome (ARDS) at high risk for pneumothorax (PNX)/pneumomediastinum (PMD), defined as the detection of the Macklin-like effect on chest computed tomography (CT) scan. DESIGN: A case series. SETTING: At the intensive care unit of a tertiary-care institution. PARTICIPANTS: Seven patients with COVID-19-associated severe ARDS and Macklin-like radiologic sign on baseline chest CT. INTERVENTIONS: Primary VV-ECMO under spontaneous breathing instead of invasive mechanical ventilation (IMV). All patients received noninvasive ventilation or oxygen through a high-flow nasal cannula before and during ECMO support. The study authors collected data on cannulation strategy, clinical management, and outcome. Failure of awake VV-ECMO strategy was defined as the need for IMV due to worsening respiratory failure or delirium/agitation. The primary outcome was the development of PNX/PMD. MEASUREMENTS AND MAIN RESULTS: No patient developed PNX/PMD. The awake VV-ECMO strategy failed in 1 patient (14.3%). Severe complications were observed in 4 (57.1%) patients and were noted as the following: intracranial bleeding in 1 patient (14.3%), septic shock in 2 patients (28.6%), and secondary pulmonary infections in 3 patients (42.8%). Two patients died (28.6%), whereas 5 were successfully weaned off VV-ECMO and were discharged home. CONCLUSIONS: VV-ECMO in awake and spontaneously breathing patients with severe COVID-19 ARDS may be a feasible and safe strategy to prevent the development of PNX/PMD in patients at high risk for this complication.

Barodontalgia and Dental Barotrauma Among Scuba Divers.

INTRODUCTION: Barometric pressure variation during dives may induce barodontalgia and barotrauma. Barodontalgia refers to oral pain resulting from a change in ambient pressure. The aim of this study was to investigate the occurrence of barodontalgia and dental barotrauma among French civilian scuba divers.METHODS: A nationwide cross-sectional internet-based survey was conducted among French scuba divers over 18 yr of age registered by the French Federation of Underwater Sports (FFESSM). The online questionnaire was distributed from October to December 2020. It contained questions regarding general characteristics of participants, barodontalgia and dental barotrauma occurrences, and relationship of the diver with his/her dentist.RESULTS: There were 684 scuba divers (65.4% men; aged 48 ± 12 yr) who participated in the study. Barodontalgia was reported by 18.7%, with some respondents reporting more than one episode. Most barodontalgia affected posterior (81.2%) and upper teeth (55.2%) with dental filling (50.0%). At least one dental barotrauma was reported by 10.1% of respondents, including mainly loss or fracture of a dental filling (4.2%). The occurrence of dental barotrauma was significantly higher among men (12.3%) than women (5.9%) and increased significantly with the age, the years of diving and the diving qualification.CONCLUSION: Information should be provided to divers on the importance of routine dental checkups.Kougeon K, Yasukawa K, Baudet A. Barodontalgia and dental barotrauma among scuba divers. Aerosp Med Hum Perform. 2022; 93(5):421-425.

Orofacial problems in scuba diving: prevalence and prevention-a large-scale survey among civilian divers in France.

Self-contained underwater breathing apparatus (SCUBA) diving is becoming widely democratized among hobbyist practitioners. It can cause orofacial problems, mostly linked to pressure changes. The aim of this study was to assess the prevalence of these problems and to analyze civilian divers' behavior about their dental prevention in France, via a cross-sectional study. Data from 1015 French civilian divers were collected via a nationwide online questionnaire in which participants indicated information concerning orofacial experienced problems during their diving activity, and their medical preventive habits. As results, oral manifestations were experienced by 25.2% of the divers, including barodontalgia (10.8%), mouth syndrome (13.4%), gum pain (2.8%) and dental fractures caused by barotrauma (3.7%) or shocks (1.9%). Mouth syndrome was more frequent among women (18.6%) and divers aged between 18 and 34 years (18.9%). The prevalence of dental fractures increased significantly with age. High diving level was associated with more frequent barodontalgia (17.5%), gum pain (7%) and barotrauma (7.6%). Among respondents, 43.5% completed a dental examination before a diving season and showed fewer oral problems during their scuba diving practice than those who did not. In conclusion, oral problems in scuba diving represent frequent events that can compromise the safety of divers. Despite awareness rising, there is a lack of recourse to the dentist. This leads to incomplete information, especially concerning the preventive means available to divers.

Barotrauma in critically ill COVID-19 patients: a retrospective case-control study.

BACKGROUND: There is increased incidence of barotrauma in COVID-19 patients, probably due to disease pathology, oxygen therapy and coughing. We aimed to retrospectively compare the characteristics, associations and outcomes of COVID-19 patients with and without barotrauma in the intensive care unit (ICU). METHODS: All adults admitted between October 1st and December 31st 2020 in the ICUs of a COVID-19 hospital were retrospectively analysed for presence of a 'barotrauma event' (presence of at least one of pneumothorax, pneumomediastinum, subcutaneous emphysema or bronchopleural fistula). A control group was formed by matching each case to a patient belonging to the same gender and age range from the remaining patients in the cohort, i.e., those without barotrauma. Demographic details, ICU stay details, details of oxygen therapy and ventilation, and outcomes were noted and compared. RESULTS: Of 827 patients, 30 patients (3.6%) developed barotrauma events. The typical patient was middle aged (median age 55.5 years) and male (73.3%). The mortality rate was significantly higher in the barotrauma group (83.3% vs. 43.3%, P < 0.001), and odds of survival decreased by 85% if barotrauma occurred (OR 0.15; 95% CI: 0.46-0.51). Patients who developed barotrauma spent a longer time on a high-flow nasal cannula (median 6.7 vs. 1.73 days, P = 0.04), and mechanical ventilation (median 9.54 vs. 0.867 days, P < 0.001), and had a longer ICU stay (median 15.5 vs. 9 days, P = 0.014). The most common event was pneumothorax (26/30). CONCLUSIONS: Barotrauma in the COVID-19 ICU is associated with prolonged ICU stay, higher odds of mortality and longer duration spent on mechanical ventilation and a high-flow nasal cannula. Key words: barotrauma, ICU, COVID-19, mortality, pneumothorax.

Incidence, clinical characteristics and outcome of barotrauma in critically ill patients with COVID-19: a systematic review and meta-analysis.

INTRODUCTION: Barotrauma is rare in patients with acute respiratory distress syndrome undergoing mechanical ventilation. Its incidence seems increased among critically ill COVID-19 patients. We performed a systematic review and meta-analysis to investigate the incidence, risk factors and clinical outcomes of barotrauma among critically ill COVID-19 patients. EVIDENCE ACQUISITION: PubMed was searched from March 1st, 2020 to August 31st, 2021; case series and retrospective cohort studies concerning barotrauma in adult critically ill COVID-19 patients, either hospitalized in the Intensive Care Unit (ICU) or invasively ventilated were included. Primary outcome was the incidence of barotrauma in COVID-19 versus non-COVID-19 patients. Secondary outcomes were clinical characteristics, ventilator parameters, mortality and length of stay between patients with and without barotrauma. EVIDENCE SYNTHESIS: We identified 21 studies (six case series, 15 retrospective cohorts). The overall incidence of barotrauma was 11 [95% CI: 8-14]% in critically ill COVID-19 patients, vs. 2 [1-3]% in non-COVID-19, P<0.001; the incidence in mechanically ventilated patients was 14 [11-17]% vs. 4 [2-5]% non-COVID-19 patients, P<0.001. There were no differences in demographic, clinical, ventilatory parameters between patients who did and did not develop barotrauma, while, on average, protective ventilation criteria were always respected. Among COVID-19 patients, those with barotrauma had a higher mortality (60 [55-66] vs. 48 [42-54]%, P<0.001) and a longer ICU length of stay (20 [14-26] vs. 13 [10,5-16] days, P=0.03). CONCLUSIONS: Barotrauma is a frequent complication in critically ill COVID-19 patients and is associated with a poor prognosis. Since lung protective ventilation was delivered, the ventilatory management might not be the sole factor in the development of barotrauma.

Ten-year Spanish cohort of diving-related injuries in a non-hyperbaric tertiary hospital on the Spanish Mediterranean coast.

INTRODUCTION: Global evidence on the epidemiology of prevalent diving-related injuries (DRI) different from decompression sickness (DCS) and other fatalities is lacking. This study aimed to perform a comprehensive review of DRIs in the year-period between 2010-2020 in a non-hyperbaric tertiary hospital in the Spanish Mediterranean coast, in addition to identifying patient risk factors for severe middle ear barotrauma. METHODS: The study was conducted via a retrospective review of medical records during a 10-year period (2010-2020) at the University and Polytechnic Hospital La Fe (UPHLF) of Valencia. We performed a case-control study recruiting controls through an online survey to identify independent predictors for severe middle ear barotrauma. RESULTS: A total of 68 patients with DRI attended the emergency department of our tertiary referral hospital. Barotrauma accounted for more than 80% of DRI, followed by unrecognized DCS and animal-related injuries. Most patients required neither hospital admission nor surgery; appropriate treatment could be carried out largely on an outpatient basis. The presence of subsequent sequelae was minimal. Previous presence of significant ear, nose and throat (ENT) comorbidities (OR 3.05 - CI 95% 1.11 - 8.35), and older age (OR of younger age 0.94 - CI 95% 0.91 - 0.98) were identified as independent risk factors for severe middle ear barotrauma, with an acceptable discrimination capacity (AUC 0.793, 95% CI 0.71 - 0.87). CONCLUSION: The incidence of DRI may be higher than previously thought, and the need to know their epidemiology, their associated morbidity, and the deficiencies of the diving management system is becoming steadily important in order to develop prevention, diagnostic and therapeutic protocols in non-hyperbaric hospitals of these regions.

Sinus Barotraumas in Commercial Aircrew.

BACKGROUND: Sinus barotraumas are a common condition in aviation medicine, sometimes compromising flight safety and even permanently grounding aircrew. Considering this and the ever-increasing amount of commercial aviation, a thorough examination is required.METHODS: In this survey study, an anonymous, electronic questionnaire was distributed to commercial aircrew of the three major commercial airlines operating in Finland (N 3799), covering 93% of the target population (i.e., all commercial aircrew operating in Finland, N 4083). Primary outcomes were self-reported prevalence, clinical characteristics, and health and occupational effects of sinus barotraumas in flight. Secondary outcomes were adjusted odds ratios (OR) for frequency of sinus barotraumas with respect to possible risk factors.RESULTS: Response rate was 47% (N 1789/3799), with 61% (N 1088) of the respondents having experienced sinus barotraumas in flight. Of those affected, 59% had used medications, 18% had undergone surgical procedures, and 53% had been on sick leave due to sinus barotraumas (38% during the last year) in flight. Factors associated with sinus barotraumas were female sex [OR, 2.47; 95% confidence interval (CI) 1.354.50] and a high number of upper respiratory tract infections (3 vs. <3 URTIs/yr: OR, 3.61; 95% CI 2.654.93).CONCLUSION: Sinus barotraumas were reported by 61% of commercial aircrew. They caused an increased need for medications, otorhinolaryngology-related surgical procedures, and sickness absence from flight duty. The possible risk factors were female sex and a high number of URTIs/yr.Lindfors OH, Ketola KS, Klockars TK, Leino TK, Sinkkonen ST. Sinus barotraumas in commercial aircrew. Aerosp Med Hum Perform. 2021; 92(11):857-863.

The effect of total compression time and rate (slope) of compression on the incidence of symptomatic Eustachian tube dysfunction and middle ear barotrauma: a Phase II prospective study.

Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are common reported complications during hyperbaric oxygen treatment. Our Phase I study data was the first to demonstrate a statistically significant decrease in the occurrence of symptomatic ETD and MEB. The Phase I Trial suggested the total time interval and rate (slope) of compression (ROC) may be a determining factor in ETD and MEB. This Phase II study investigates an optimal rate of compression to reduce ETD and MEB when considering each multiplace treatment (with multiple patients) as the unit of observation as a group, rather than for each individual patient. Data were collected prospectively on 1,244 group patient-treatment exposures, collectively including 5,072 individual patient-treatment/exposures. We randomly assigned patient-treatment group exposures to four different time interval and rate (slope) of compression. These compression rates and slopes were identical to those used in the Phase I trial. All patients experiencing symptoms of MEB requiring compression stops were evaluated post treatment for the presence of ETD and MEB using the O'Neill Grading System (OGS) for ETD. Data were analyzed using the IBM-SPSS statistical software program. A statistically significant decrease in the number of compression holds was observed in the 15-minute compression schedule, correlating to the results observed in the Phase I trial. The 15-minute linear compression profile continues to demonstrate the decreased need for patient symptomatic compression stops (as in the Phase I trial) using a USN TT9 during elective hyperbaric oxygen treatments in a Class A multiplace hyperbaric chamber. Trial Registration: ClinicalTrials.gov Identifier: NCT04776967.

Outcomes of Barotrauma in Critically Ill COVID-19 Patients With Severe Pneumonia.

BACKGROUND: Pneumomediastinum and pneumothorax are complications which may be associated with barotrauma in mechanically ventilated patients. The current literature demonstrates unclear outcomes regarding barotrauma in critically ill patients with severe COVID-19. The purpose of this study was to examine the incidence of barotrauma in patients with severe COVID-19 pneumonia and its influence on survival. STUDY DESIGN AND METHODS: A retrospective cohort study was performed from March 18, 2020 to May 5, 2020, with follow-up through June 18, 2020, encompassing critically ill intubated patients admitted for COVID-19 pneumonia at an academic tertiary care hospital in Brooklyn, New York. Critically ill patients with pneumomediastinum, pneumothorax, or both (n = 75) were compared to those without evidence of barotrauma (n = 206). Clinical characteristics and short-term patient outcomes were analyzed. RESULTS: Barotrauma occurred in 75/281 (26.7%) of included patients. On multivariable analysis, factors associated with increased 30-day mortality were elevated age (HR 1.015 [95% CI 1.004-1.027], P = 0.006), barotrauma (1.417 [1.040-1.931], P = 0.027), and renal dysfunction (1.602 [1.055-2.432], P = 0.027). Protective factors were administration of remdesivir (0.479 [0.321-0.714], P < 0.001) and receipt of steroids (0.488 [0.370-0.643], P < 0.001). CONCLUSION: Barotrauma occurred at high rates in intubated critically ill patients with COVID-19 pneumonia and was found to be an independent risk factor for 30-day mortality.