Discussion
The COVID19, has caused over 300 million cases and more than 5.4 million deaths globally since 2019(1, 2).Although most cases of COVID-19 infection exhibit primarily constitutional and respiratory tract symptoms (such as fever, fatigue, myalgias, dry or productive cough, and dyspnea) similar to any other pulmonary viral infection(1, 2). Concerning the pulmonary manifestations of COVID-19, other than pneumonia and acute respiratory distress syndrome, various complications have been reported, which are not routinely seen in other types of respiratory viral infections (1-3). These include a prolonged infectious state, lung fibrosis, bullous lung disease, pleural effusion, pulmonary cysts, spontaneous pneumothorax, and pneumomediastinum amongst others (8, 9). Most of the patients who die from COVID-19 infection have the respiratory system as the primary organ involved (10).
Tension pneumomediastinum is a rare but potentially lethal condition seen in critically ill patients. Traditionally, pneumomediastinum occurs in young patients with asthma(1, 11). During an asthmatic attack, rapid breathing causes alveolar rupture into the lower-pressure mediastinum. This condition is often harmless and resolves spontaneously as air is absorbed with time..(3, 11) .On the other hand, tension pneumomediastinum can also occur due to prolonged mechanical ventilation, particularly in settings of high end-expiratory pressure(12). Understandably so, this complication has seen an increase in incidence following the emergence of the COVID-19 pandemic, as high end-expiratory pressure ventilation has been utilized to a greater extent for management of COVID-19–related respiratory distress (1, 11). This form of pneumomediastinum is far more complicated and requires urgent intervention(11).
Tension pneumomediastinum is thought to occur in patients with COVID-19 secondary to diffuse alveolar damage(11, 13) as our patient . The increased presence of diseased alveoli on the mediastinal surface allows for preferential rupture into the mediastinum due to the pressure gradient between the alveoli and the perivascular sheaths (11). Further spreading of the pulmonary interstitial emphysema into the mediastinum is subsequently known as the Macklin effect(9). In patients with COVID-19, the diseased lung may create a one-way valve at the mediastinal pleural border, which can subsequently lead to air retention in the mediastinum (11). Increased pressure in the mediastinum can compress mediastinal contents. In particular, compression of the great vessels can lead to decreased venous return, hypotension with tachycardia, and potential cardiovascular collapse (9, 11, 14)
Currently, management for tension pneumomediastinum in the COVID-19 population has largely been conservative(12, 15). Different approaches include reducing airway pressures and adjusting ventilator settings to allow for permissive hypercapnia in an effort to reduce pressure gradients across the mediastinal surface (3, 15). These methods may be sufficient for the management of tension pneumomediastinum in stable COVID-19 patients (11, 15), but those who are unstable may require immediate surgical decompression. After review of the current literature, Some describe cases report of operative management for a massive tension pneumomediastinum secondary to COVID-19 (12, 14, 15).Of note, there was some previous report of tension pneumomediastinum secondary to COVID-19 that resolved with bedside mediastinotomy via the Chamberlain procedure(11, 14-16)
In our patient with COVID-19, a tension pneumomediastinum formed in the chest and SE in the neck, with subsequent spread to the arms bilaterally and with the enlarging pneumomediastinum caused difficulty breathing and progressive dysphonia with an increased pitch in the tone of his voice and engorge the jugular vein with cyanosis of face. Due to impending airway obstruction, the patient was sent for emergent mediastinal drainage with bilaterally chest tube insertion in anterior mediastinum and bilaterally sub-clavicular incision for evacuation of SE. In some report they created a subxiphoid pericardial window, employed subxiphoid and suprasternal drainage of the pneumomediastinum, and performed substernal dissection with lighted scope (11, 14-16) but we used bilaterally chest tube insertion in the anterior mediastinum. With these surgical managements, the anterior mediastinum was decompressed, resulting in rapidly reduced swelling in the patient’s neck, improvement of his voice, and disappearance of the crepitus with clinical and radiographic healing but chest tube insertion is simple and available in emergency room or intensive care unit.
We describe the first minor invasive operative management of massive tension pneumomediastinum secondary to COVID19 infection. We used chest tube insertion that provided rapid decompression of unstable tension pneumomediastinum with mediastinal drainage. This case demonstrates that precipitous decline may occur in a patient with diseased lung parenchyma such as COVID-19, and that our method may offer an effective operative solution for rapid decompression required for massive tension pneumomediastinum and subcutaneous emphysema.