Pneumomediastinum and air leaks secondary to COVID-19: Expectant vs. invasive management of a rare complication.

Several alterations that, due to their pathophysiology, are collectively classified as "air leaks", have been rare complications of COVID-19 pneumonia. In the context of infection by SARS-CoV-2, the debate arises as to whether these are classified as spontaneous or secondary, since the multiple mechanisms of pulmonary structural damage that COVID-19 entails condition lung fragility in a patient in short time. For the above, we presents the case of a 36-year-old female patient with COVID-19 complicated with pneumomediastinum and subcutaneous emphysema in order to illustrate and discuss these complications.

Diversas alteraciones que, por su fisiopatología, son clasificadas en conjunto como «fugas de aire¼, han sido complicaciones raras de la neumonía por COVID-19. Respecto a la infección por SARS-CoV-2, se plantea el debate de si estas se clasifican como espontáneas o secundarias, ya que los múltiples mecanismos de daño estructural pulmonar que conlleva la COVID-19 condicionan fragilidad pulmonar en corto lapso. Por lo anterior, se expone el caso de una paciente de 36 años con COVID-19 complicada con neumomediastino y enfisema subcutáneo con el objetivo de ilustrar y discutir dichas complicaciones.

Isolated subcutaneous emphysema of the abdominal wall following endoscopic retrograde cholangiopancreatography.

Isolated subcutaneous emphysema without retroperitoneal perforation is a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). We present the case of an 87-year-old female who developed extensive subcutaneous emphysema following ERCP for choledocholithiasis. Abdominal computed tomography showed air perfectly dissecting the abdominal wall muscle layers and no evidence of an air leak in the pleural, mediastinal, or peritoneal spaces.

Spontaneous pneumomediastinum in COVID-19 patients. Case series.

Spontaneous pneumomediastinum is defined as the presence of free air within the mediastinum without an apparent cause such as chest trauma. It is a benign, self-limiting condition that is conservatively treated. Clinical diagnosis is based on two symptoms: chest pain and dyspnea; and on a particular sign: subcutaneous emphysema. It has been reported in patients with influenza A (H1N1) and severe acute respiratory syndrome; however, it has been rarely observed in COVID-19 patients. In this work, we describe six male patients with COVID-19, aged between 27 and 82 years, who presented with spontaneous pneumomediastinum and subcutaneous emphysema; both conditions were completely resorbed with conservative management.

El neumomediastino espontáneo es la presencia de aire libre en el mediastino sin el antecedente de alguna causa como trauma de tórax. Es una condición benigna autolimitada que se trata en forma conservadora. El diagnóstico clínico se basa en dos síntomas: dolor torácico y disnea; y en un signo en particular: enfisema subcutáneo. Ha sido reportado en pacientes con influenza A (H1N1) y síndrome respiratorio agudo grave; sin embargo, ha sido raramente observado en pacientes con COVID-19. En este trabajo describimos seis pacientes del sexo masculino con COVID-19, con edades entre 27 y 82 años, que presentaron neumomediastino espontáneo y enfisema subcutáneo; ambos se reabsorbieron totalmente con manejo conservador.

Neumomediastino espontáneo en pacientes COVID-19. Serie de casos / Spontaneous pneumomediastinum in COVID-19 patients. Case series

Resumen El neumomediastino espontáneo es la presencia de aire libre en el mediastino sin el antecedente de alguna causa como trauma de tórax. Es una condición benigna autolimitada que se trata en forma conservadora. El diagnóstico clínico se basa en dos síntomas: dolor torácico y disnea; y en un signo en particular: enfisema subcutáneo. Ha sido reportado en pacientes con influenza A (H1N1) y síndrome respiratorio agudo grave; sin embargo, ha sido raramente observado en pacientes con COVID-19. En este trabajo describimos seis pacientes del sexo masculino con COVID-19, con edades entre 27 y 82 años, que presentaron neumomediastino espontáneo y enfisema subcutáneo; ambos se reabsorbieron totalmente con manejo conservador.

Abstract Spontaneous pneumomediastinum is defined as the presence of free air within the mediastinum without an apparent cause such as chest trauma. It is a benign, self-limiting condition that is conservatively treated. Clinical diagnosis is based on two symptoms: chest pain and dyspnea; and on a particular sign: subcutaneous emphysema. It has been reported in patients with influenza A (H1N1) and severe acute respiratory syndrome; however, it has been rarely observed in COVID-19 patients. In this work, we describe six male patients with COVID-19, aged between 27 and 82 years, who presented with spontaneous pneumomediastinum and subcutaneous emphysema; both conditions were completely resorbed with conservative management.

Benign recurrent subcutaneous emphysema of the upper limbs in a teenager / Enfisema subcutáneo benigno recurrente de las extremidades superiores en una adolescente

Background: The physiological properties of the interstitial subcutaneous tissue of the limbs could bring the abnormal distribution of air coming from superficial trauma of the skin. We present the case of a young woman who developed subcutaneous emphysema after a superficial trauma and discussed the differential diagnosis and treatment. Clinical case: A teenager woman 13 years old had subcutaneous emphysema in the left arm, following the scratch produced by her cat, of two months of evolution, without signs suggestive of local or systemic infection, it was resolved spontaneously during the period of observation. During this period she also presented subcutaneous emphysema in the right arm as a complication of a peripheral venous access performed for the administration of parenteral solutions, in the same way, it resolved spontaneously within a few days. Conclusion: Benign subcutaneous emphysema is a rare clinical condition which should be considered only after the exclusion of other pathologies that require a more aggressive early medical intervention, such as necrotizing fasciitis, which, if not detected in a timely manner, could endanger life.

Introducción: las propiedades fisiológicas del tejido celular subcutáneo de las extremidades pudieran favorecer la distribución anormal de aire proveniente de traumatismos superficiales de la piel. Presentamos el caso de una joven mujer quien desarrolló enfisema subcutáneo posterior a traumatismos superficiales y discutimos el diagnóstico diferencial y tratamiento. Caso clínico: mujer de 13 años, con signos de enfisema subcutáneo en el brazo izquierdo, posterior al rasguño producido por su gato, de dos meses de evolución, sin signos sugestivos de infección local o sistémica, el cual remitió en forma espontánea durante el periodo de observación. Durante este lapso también presentó enfisema subcutáneo en el brazo derecho, como complicación de un acceso venoso periférico realizado para la administración de soluciones parenterales, igualmente remitió espontáneamente a los pocos días. Conclusión: el enfisema subcutáneo benigno es una condición clínica rara, debe considerarse únicamente después de la exclusión de otras patologías que requieren de una intervención médica temprana más agresiva como en la fascitis necrotizante, la cual de no ser detectada oportunamente pudiera poner en peligro la vida.

[Spontaneous pneumomediastinum and subcutaneous emphysema associated with bronchospasm in a woman with no history of asthma]. / Neumomediastino espontáneo y enfisema subcutáneo asociado con broncoespasmo en una mujer sin antecedente de asma.

BACKGROUND: Spontaneous pneumomediastinum most relevant triggering events are cough, vomiting, nutritional problems, physical activity and use of inhaled drugs. Association of spontaneous pneumomediastinum with non-asthma-related bronchospasm is an infrequent event. CLINICAL CASE: This is the case of a 21-year-old woman without personal or family history of asthma, allergic rhinitis or atopy who during late puerperium had 39 °C fever, paroxysmal cough and chest oppression of sudden onset, as well as wheezing and subcutaneous emphysema of the neck; she had no previous nasal symptoms. Chest X-ray revealed free air in the mediastinum and left lateral side of the neck. Possible cause of the condition was attributed to bronchospasm related to airway infection. Treatment was based on bronchodilators, systemic steroids and supplementary oxygen administration. The symptoms subsided after 48 hours. CONCLUSIONS: In the clinical case herein presented, spontaneous pneumomediastinum precipitating factor appeared to be paroxysmal cough associated with bronchospasm and, hence, we suggest for this entity to be suspected in patients even if there is no previous history of asthma.

Antecedentes: Los desencadenantes del neumomediastino espontáneo de mayor relevancia son tos, vómito, problemas de alimentación, actividad física y el uso de drogas inhaladas. La asociación de neumomediastino espontáneo con broncoespasmo no relacionado con asma es un suceso inusitado. Caso clínico: Mujer de 21 años de edad sin antecedentes personales ni familiares de asma, rinitis alérgica o atopia, quien durante la etapa del puerperio tardío presentó súbitamente fiebre de 39 °C, disnea, tos paroxística y opresión torácica, así como sibilancias y enfisema subcutáneo en el cuello; no presentó síntomas nasales previos. La radiografía de tórax evidenció aire libre en mediastino y cara lateral izquierda del cuello. La posible causa del cuadro se atribuyó al broncoespasmo relacionado con infección de las vías respiratorias. El tratamiento consistió en la administración de broncodilatadores, esteroides sistémicos, antibióticos y oxígeno suplementario. La sintomatología remitió después de 48 horas. Conclusión: En el caso clínico descrito, al parecer el factor precipitante del neumomediastino espontáneo fue la tos paroxística asociada con el broncoespasmo, de tal forma que sugerimos se sospeche en los pacientes aun cuando no existan antecedentes de asma.

Enfisema subcutáneo masivo, nemotórax a tensión y neumomediastino tras traqueotomía percutánea / Massive subcutaneous emphysema, nemotórax voltage and pneumomediastinum after percutaneous tracheostomy

Mujer de 68 años que ingresa en la Unidad de Cuidados Intensivos por shock séptico. En el posoperatorio la paciente se mantiene inestable y se decide realizar traqueotomía percutánea (TP) por intubación prolongada. Al inicio la paciente presenta un enfisema subcutáneo que progresa hasta convertirse en masivo. Se realiza TC torácico donde se observa pérdida de la morfología habitual de la pared posterior traqueal con solución de continuidad. Tras revisión mediante traqueobroncoscopía se decide colocar cánula de traqueotomía larga para dejar la lesión proximal al neumotaponamiento y así evitar la fuga de aire. Desde la colocación de la nueva cánula, la paciente presenta una disminución progresiva del enfisema hasta su total resolución. La TP es un procedimiento seguro que se realiza con mucha frecuencia en los servicios de medicina intensiva, sin embargo, no está exenta de complicaciones. En la revisión de Powell y cols describen las complicaciones de la TP destacando la inserción peritraqueal, la hemorragia, las infecciones de la herida, el neumotórax y la muerte. El rango de complicaciones en la literatura oscila entre 3% y 18%. Además, no se encuentran diferencias significativas respecto a las complicaciones entre la TP y la técnica abierta.

A 68-year-old woman who enter in intensive care unit due to septic shock. In the postoperative period, the patient remained unstable and decided to perform a percutaneous tracheotomy (PT) because prolonged intubation. In the first, the patient presents subcutaneous emphysema that progresses until becoming massive. Thoracic CT is performed where loss of the usual morphology of the posterior tracheal wall with continuity solution is observed. After revision by means of tracheobroncoscopia, it is decided to place a long tracheotomy cannula to leave the lesion proximal to pneumotaponamiento and thus avoid air leakage. From the placement of the new cannula, the patient presents a progressive decrease of the emphysema until its total resolution. PD is a safe procedure that is performed very frequently in the Intensive Care Services3, however, it is not without its complications. The review of Powell et al4 describes the complications of PT emphasizing peritracheal insertion, hemorrhage, wound infections, pneumothorax, and death. The range of complications in the literature ranges from 3 to 18% 5. In addition, no significant differences were found regarding the complications between the TP and the open technique.

[Blunt chest trauma with pneumomediastinum and pneumoperitoneum secondary to Macklin effect. Case report]. / Trauma contuso de tórax con neumomediastino y neumoperitoneo secundario a efecto Macklin. Reporte de un caso.

BACKGROUND: Pneumomediastinum is the presence of free air around mediastinal structures, which may be spontaneous or secondary, and can occur in 10% of patients with blunt chest trauma, with the Macklin effect being its main pathophysiology. CLINICAL CASE: A 21 year old male, hit by motor vehicle, with alvéolopalatal fracture and blunt chest trauma, who, 72 hrs after admission, shows subcutaneous emphysema in the anterior chest. A simple tomography of the chest and abdomen was performed, finding a pneumomediastinum, bilateral pulmonary contusions and pneumoperitoneum. Oesophageal, tracheobronchial or intra-abdominal viscera injuries were ruled out, establishing the cause of pneumomediastinum and pneumoperitoneum due to the Macklin effect. This required conservative management in intensive care unit, with a favourable clinical course and discharged after a 10 day hospital stay. DISCUSSION: Macklin effect is caused by dissection of air medially along the bronchoalveolar sheath (interstitial emphysema), secondary to alveolar breakdown and extending into mediastinal and other anatomical structures (pneumoperitoneum). It has been documented in blunt trauma, as well as in acute asthma, positive pressure ventilation, or after Valsalva manoeuvres. The imaging method of choice is computed tomography, and its characteristic findings, interstitial emphysema adhering to a bronchus and pulmonary blood vessel. CONCLUSIONS: In the presence of pneumomediastinum and pneumoperitoneum is necessary to rule out oesophageal and tracheobronchial injury before establishing the Macklin effect as its cause. The diagnosis is made with computed tomography and managed conservatively.

[Postpartum spontaneous pneumomediastinum and subcutaneous emphysema]. / Neumomediastino y enfisema subcutáneo espontaneos postparto: informe de un caso.

Spontaneous pneumomediastinum is the presence of free air contained within the mediastinum, frequently associated with subcutaneous emphysema and of atraumatic origin. Frequency during childbirth is 1 in 100,000. We report the case of a 19 year old woman without respiratory disease history, in her first pregnancy with 39.5 weeks of gestation patient had, prolonged latent phase and sudden postpartum onset of dyspnea, thoracic pain and subcutaneous emphysema. Simple X ray film and thoracic tomography revealed the presence of free air in the mediastinum. The association of pneumomediastinum during delivery is an uncommon event.

[Orbital emphysema after Valsalva maneuver. Report of one case]. / Enfisema orbitario espontáneo tras la maniobra de Valsalva.

Orbital emphysema is a rare complication of orbital and facial trauma, involving the sinuses and occasionally the nasal cavity. Most cases occur as a result of trauma but spontaneous orbital emphysema has been reported. Clinical manifestations are often delayed until the upper airway pressure increases as when blowing or coughing. Along with the fracture, the rupture of the underlying mucosa is essential for emphysema to manifest. We report a 29-years-old male who consulted in the emergency room due to eyelid swelling after a Valsalva maneuver, a couple of hours after suffering a facial injury secondary to a fall. In the presence of eyelid emphysema, the patient underwent craniofacial imaging studies, confirming an ethmoidal lamina papyracea fracture.

Periorbital subcutaneous emphysema in rhinoplasty.

In this article, the authors present a case of postrhinoplasty periorbital subcutaneous emphysema in a 35-year-old woman. This is an uncommon and benign rhinoplasty complication that can sometimes result from other pathologies such as barotrauma, hematoma, and allergic reaction. This patient's symptoms appeared to be a result of postanesthesia agitation. The patient's symptoms resolved after 1 week.

[Pneumoperitoneum, pneumoretroperitoneum, bilateral pneumothorax, pneumomediastinum and subcutaneous emphysema due ERCP]. / Neumoperitoneo, neumoretroperitoneo, neumotórax bilateral, neumomediastino y enfisema subcutáneo secundario a CPRE.

Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential procedure in the diagnosis and treatment of biliopancreatic diseases. Complications of this procedure are potentially serious, being necessary to know how to recognize them for the application of the appropriate treatment. We report the case of a 79-year-old woman who developed a massive subcutaneous emphysema, bilateral pneumothorax, retropneumomediastinum, retropneumoperitoneum and pneumoperitoneum due to iatrogenic duodenal injury secondary to ERCP. The clinical suspicion for early diagnosis of iatrogenic injury after ERCP will determine the correct treatment of this complication and will achieve better outcomes.

Subcutaneous emphysema during third molar surgery: a case report.

Extraction of third molars is the most common surgical procedure performed in oral surgery on a daily basis and, despite surgical skills and expertise, complications may occur. Complications observed during or after third molar removal may include pain, swelling, bleeding, infection, sinus perforation and nerve damage. Fortunately, with a proper management and a good surgical technique, the incidence of such events is low. Subcutaneous emphysema associated with dental extraction occurs when the air from the high-speed dental handpiece is forced into the soft tissue through the reflected flap and invades the adjacent tissues, leading to swelling, crepitus on palpation and occasionally spreading through the tissue spaces of the fascial planes. Although rare, iatrogenic subcutaneous emphysema can have serious and potentially life-threatening consequences. Care should be taken when using air-driven handpieces. The access of air into the facial tissues is not limited to tooth extractions, but may also occur through other portals of entrance, such as endodontically treated teeth, periodontium and lacerations of intraoral soft tissues. When subcutaneous emphysema occurs, it must be quickly diagnosed and properly managed to reduce the risk of further complications. This report presents a case of subcutaneous emphysema occurred during extraction of a mandibular third molar extraction with the use of an air turbine handpiece. Case management is described and issues relative to the diagnosis and prevention of this surgical complication are discussed.