Case 1
A 51-year-old man without a history of previous medical illness presented in May 2020 with severe COVID-19 pneumonia. He had shortness of breath and low oxygen saturation, requiring noninvasive ventilation in the initial period. His chest radiographs showed bilateral peripheral infiltrates. He was managed as per the hospital COVID-19 protocol at that time. Initially, he was advised self-prone position with oxygen supplementation; but on the 4th day, his condition deteriorated, requiring intubation and ventilation. During his stay in ICU, he developed a cytokine storm requiring IL-6 antagonist Tocilizumab and steroids. He had a prolonged course of invasive ventilation during which his position was changed to prone multiple times. He received convalescent plasma and was successfully extubated on the 15th day after improvement in ventilatory settings. He remained stable for the next 4 days but developed severe sepsis, leading to septic shock and ARDS, eventually leading to reintubation. Sputum cultures grewStenotrophomonas maltophilia and Klebsiella , which was extended-spectrum beta-lactamase resistant (ESBL).
Ventilator support continued for another 8 days, and on day 28th after his admission, he developed extensive lower neck and chest wall subcutaneous emphysema. Chest x-ray (CXR) showed pneumo-mediastinum (Figure 1). No evident pneumothorax was noted on the CXR on that day. During this period, he had been on high ventilatory settings, including controlled mandatory ventilation (CMV) with Fio2 50%, tidal volume 350ml, PEEP of 8 mmHg, and Respiratory rate of 30/minute.
CT scan was done, which showed extensive pneumomediastinum and bilateral pneumothorax. A small suspicious area of possible disintegration and discontinuation within the right posterolateral wall of the lower part of the trachea was noticed (Tracheal tear). Bilateral diffuse ground-glass opacities were observed bilaterally in the lung fields, which were consistent with his underlying ARDS. (Figure 2)
Right side chest drain was inserted to relieve the tension pneumothorax. His condition deteriorated in the next few days due to multi-organ failure, and the patient expired on day 36 in the ICU.