Case 2
A 71-year-old man with a past medical history of osteoarthritis and hypertension bring managed with amlodipine presented to the hospital with signs of COVID-19 pneumonia and moderate ARDS. He was initially managed with a non-rebreathing oxygen mask, self-proning, and noninvasive ventilation. He was managed with antibiotics, antivirals, steroids, and as he showed signs of cytokine storm, IL-6 antagonist Tocilizumab was given. Later, he also received convalescent plasma from recovered COVID-19 donors. The management was done according to the hospital’s COVID-19 management guidelines. During his course in the hospital, he developed hospital-acquired secondary pneumonia fromEnterobacter cloacae , Candida , and Acinetobacter baumanni . Bronchoalveolar lavage grew Stenotrophomonas maltophilia . He was intubated and ventilated on day 32 in the hospital due to worsening of ARDS, sepsis, multiorgan dysfunction syndrome (MODS).
Ventilatory requirements remained high during this period and on day 37, his chest radiographs showed pneumomediastinum, subcutaneous emphysema with no pneumothorax. His ventilator settings on that day were CMV mode with FiO2 40%, positive end-expiratory pressure
(PEEP) of 8mmHg, tidal volume 370 ml, and respiratory rate of 26/minute.
Computerized topography (CT) scan showed extensive surgical emphysema in the neck and anterior-lateral aspect of the chest wall, which was more prominent in the right side. Extensive tension pneumo-mediastinum was noted extending from the superior mediastinum, anterior mediastinum, posterior mediastinum and extending even to the retroperitoneum space surrounding the pancreas and left kidney. No evidence of pneumoperitoneum was found. Bilateral thin rim of pneumothorax was noted slightly more on the left side. No evidence of lung collapse was seen in the CT scan.
Conservative management was adopted for his pneumo-mediastinum by reducing the ventilator pressures and close observation. The condition resolved over time. He was tracheostomized on day 12 due to a prolonged ventilatory course. He developed recurrent sepsis during his stay in the ICU; however, due to timely management, his condition improved over time. The patient was discharged from the ICU on day 29.