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.