Subcutaneous Emphysema and Pneumomediastinum in patients with CoVID-19 disease; Case series from a tertiary care hospital in Pakistan

Since December 2019, the clinical symptoms of COVID-19 and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema. We report ten patients of COVID-19, with subcutaneous emphysema and pneumomediastinum. The mean age of the patients was 59±8 years (range, 23-97). Majority of them were men (80%), and common symptoms were dyspnea (100%), fever (80%), and cough (80%). None of them had an underlying lung disorder. All patients had ARDS on admission, with a median PaO2/FiO2 ratio of 122.5. Eight of the patients had spontaneous pneumomediastinum on their initial chest X-ray in emergency department. The median duration of assisted ventilation before the development of subcutaneous emphysema was 5.5 days (interquartile range, 5-10 days). The highest PEEP for invasively ventilated patients was 10 cmH20, while 16 cmH20 was the average PEEP in non-invasively ventilated patients. All patients received corticosteroids while 6 also received tocilizumab, and 7 received convalescent plasma therapy respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8 to 25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to CoVID-19 triggered by use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and subcutaneous emphysema are rare complications in critically ill CoVID-19 ARDS patients and associated with worse prognosis.