Pneumomediastinum, pneumothorax and pleural empyema in patients with Covid-19

Introduction. Since the beginning of the spread of Covid-19, publications have appeared regarding pneumomediastinum against the background of coronavirus infection, but the data in them are insufficient. Pneumomediastinum against the background of the spread of Covid-19 can be a source of serious concern for clinicians.

The aim of the study is to present data on new, frequent observations of pneumomediastinum, combined with pneumothorax and hydropneumothorax in patients with Covid-19, with various clinical manifestations and course, as well as to determine treatment tactics.

Materials and method. A study of the treatment results of 5301 patients with Covid-19, aged 19 to 104 years. Pneumomediastinum was confirmed by computed tomography. All patients with pneumothorax, pneumo-hydrothorax and empyema pleura were drained using the Pleuracan drainage system (B.Braun) or silicone drains, followed by active aspiration.

Results. Pneumomediastinum did not require any interventions in any case, against the background of the treatment, the situation was resolved independently, as the air resorbed. In pneumothorax, active aspiration was carried out until the lung was completely straightened to achieve reliable sealing, from six days to two weeks. All 26 patients with pneumothorax who were on mechanical ventilation died, but in no casepneumothorax was the direct cause of death.

Conclusion. Pneumomediastinum, especially in combination with pneumothorax, can complicate the course of severe coronavirus infection. Combination with pneumothorax requires drainage of the pleural cavity, at the same time, the pneumomediastinum needs only conservative management. In all cases the least traumatic and safest methods of treatment should be chosen.

1. Polyantsev A.A., Panin S.I., Kotrunov V.V. Pneumomediastinum in patients with a novel coronavirus infection (COVID-19). Khirurgiya. Zurnal im. N.I. Pirogova, 2021, № 5, pp. 20–24. (In Russ.) https://doi.org/10.17116/hirurgia202105120

2. Lesteva N.А., Аdieva E.V., Lesina S.S., Аibazova M.I., Аbramov K.B., Sebelev K.I., Kondratiev А.N. COVID-19. Pneumonia Pneumomediastinum. Clinical Cases. Messenger of ANESTHESIOLOGY AND RESUSCITATION, 2021, vol. 18, № 3, pp. 23–29. (In Russ.) https://doi.org/10.21292/2078-5658-2021-18-3-23-29

3. ОTseĭmakh E.A., Levin A.V., Shvetsov I.V., Broder I.A. Application of endobronchial valve occlusion and videothoracoscopy in complex treatment of pyopneumothorax. Endoscopic Surgery, 2011, vol. 17, № 2, pp. 14–17. (In Russ.)

4. Sutherland F., Campanella C. Pneumomediastinum during spontaneous vaginal delivery. Ann. Thorac. Cardiovasc. Surg., 2002, vol. 73, pp. 314–315. https://doi.org/10.1016/s0003-4975(01)02729-1

5. Gerazounis M., Athanassiadi K., Kalantzi N., Moustardas M. Spontaneous pneumomediastinum. A rare benign entity. J. Thorac. Cardiovasc. Surg., 2003, vol. 126, pp. 774–776. https://doi.org/10.1016/s0022-5223(03)00124-7

6. Morris J.B., Shuck J.M. Pneumomediastinum in a young male cocaine user. Ann Emerg Med., 1985, vol. 14, pp. 194–196. https://doi.org/10.1016/s0196-0644(85)81104-5

7. Birrer R.B., Calderon J. Pneumothorax. Pneumomediastinum and pneumopericardium following Valsalva’s maneuver during marijuana smoking. NY State J. Med., 1984, vol. 12, pp. 619–620.

8. Manço J.C., Terra-Filho J., Silva G.A. Pneumomediastinum, pneumothorax and subcutaneous emphysema following the measurement of maximal expiratory pressure in a normal subject. Chest, 1990, vol. 98, pp. 1530–1532. https://doi.org/10.1378/chest.98.6.1530

9. Maunder R.J., Pierson D.J., Hudson L.D. Subcutaneous and mediastinal emphysema: pathophysiology, diagnosis and management. Arch. Intern. Med., 1984, vol. 144, pp. 1447–1453.

10. Macia I., Moya J., Ramos R., Morera R., Escobar I., Saumench J., Perna V., Rivas F. Spontaneous pneumomediastinum: 41 cases. European Journal of Cardio-Thoracic Surgery, 2007, vol. 31, pp. 1110–1114. https://doi.org/10.1016/j.ejcts.2007.03.008

11. Zabozlaev F.G., Kravchenko E.V., Gallyamova A.R., Letunovsky N.N. Pulmonary pathology of the new coronavirus disease (COVID-19). The preliminary analysis of post-mortem findings. Journal of Clinical Practice, 2020, vol. 11, № 2, pp. 21–37. https://doi.org/10.17816/clinpract34849

12. Macklin M.T., Macklin C.C. Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: interpretation of clinical literature in light of laboratory experiment. Medicine, 1944, vol. 23, pp. 281–358.

13. Yelli A., Conway E.E. Spontaneous pneumomediastinum. Chest, 1992, vol. 101, pp. 1743. https://doi.org/10.1378/chest.101.6.1742b

14. Wintermark M., Schnyder P. The Macklin effect. A frequent etiology for pneumomediastinum in severe blunt chest trauma. Chest, 2001, vol. 120, pp. 543–547. https://doi.org/10.1378/chest.120.2.543

15. Hamman L. Spontaneous mediastinal emphysema. Bull Johns. Hopkins Hosp.,1939, vol. 64, pp. 1–21.