Barotrauma in Coronavirus Disease 2019 Patients Undergoing Invasive Mechanical Ventilation: A Systematic Literature Review.

OBJECTIVE: There are concerns of a high barotrauma rate in coronavirus disease 2019 patients with acute respiratory distress syndrome receiving invasive mechanical ventilation. However, a few studies were published, and reported rates were highly variable. We performed a systematic literature review to identify rates of barotrauma, pneumothorax, and pneumomediastinum in coronavirus disease 2019 acute respiratory distress syndrome patients receiving invasive mechanical ventilation. DATA SOURCE: PubMed and Scopus were searched for studies reporting barotrauma event rate in adult coronavirus disease 2019 patients receiving invasive mechanical ventilation. STUDY SELECTION: We included all studies investigating adult patients with coronavirus disease 2019 acute respiratory distress syndrome requiring mechanical ventilation. Case reports, studies performed outside ICU setting, and pediatric studies were excluded. Two investigators independently screened and selected studies for inclusion. DATA EXTRACTION: Two investigators abstracted data on study characteristics, rate of pneumothorax, pneumomediastinum and overall barotrauma events, and mortality. When available, data from noncoronavirus disease 2019 acute respiratory distress syndrome patients were also collected. Pooled estimates for barotrauma, pneumothorax, and pneumomediastinum were calculated. DATA SYNTHESIS: A total of 13 studies with 1,814 invasively ventilated coronavirus disease 2019 patients and 493 noncoronavirus disease 2019 patients were included. A total of 266/1,814 patients (14.7%) had at least one barotrauma event (pooled estimates, 16.1% [95% CI, 11.8-20.4%]). Pneumothorax occurred in 132/1,435 patients (pooled estimates, 10.7%; 95% CI, 6.7-14.7%), whereas pneumomediastinum occurred in 162/1,432 patients (pooled estimates, 11.2%; 95% CI, 8.0-14.3%). Mortality in coronavirus disease 2019 patients who developed barotrauma was 111/198 patients (pooled estimates, 61.6%; 95% CI, 50.2-73.0%). In noncoronavirus disease 2019 acute respiratory distress syndrome patients, barotrauma occurred in 31/493 patients (6.3%; pooled estimates, 5.7%; 95% CI, -2.1% to 13.5%). CONCLUSIONS: Barotrauma occurs in one out of six coronavirus disease 2019 acute respiratory distress syndrome patients receiving invasive mechanical ventilation and is associated with a mortality rate of about 60%. Barotrauma rate may be higher than noncoronavirus disease 2019 controls.

Anatomical meningo-orbital band evaluation and clinical implications: a cadaveric dissection study.

BACKGROUND: The meningo-orbital band (MOB) is a dural structure which runs around the superior orbital fissure (SOF) tethering the frontotemporal basal dura to the periorbita, through the SOF. MOB division is important to expose and remove the anterior clinoid process, to access to proximal carotid artery and cavernous sinus area. The aim of this study was to measure how the MOB could be safely incised without cranial nerves and cavernous sinus injuries. METHODS: Anatomical dissections and extradural exposure of the anterior clinoid process was performed on 20 cadavers (40 sides). Measurement of the MOB thickness was performed before its incision, after dura propria dissection, and retraction off the inner cavernous membrane, to expose the cranial nerves. RESULTS: We analyzed 20 cadaveric formalin-fixed heads injected with colored silicone, 11 man and 9 women of Caucasian race. The average length of a safe incision of the MOB was 10.6±1.1 mm on the right side, and 10.65±1.09 mm on the left side. CONCLUSIONS: In our study the average length of a safe incision of the MOB was 10.6±1.1 mm. Thus, the incision length of the MOB should not exceed 9 mm; the peeling of the anterior cavernous sinus and of the SOF, dissecting the two layers of the dura throughout the incision of the MOB, is a useful technique to avoid cranial nerves and cavernous sinus lesions.