Pulmonary Barotrauma Resulting from Mechanical Ventilation in 2 Patients with a Diagnosis of COVID-19 Pneumonia.

BACKGROUND Invasive mechanical ventilation can cause pulmonary barotrauma due to elevated transpulmonary pressure and alveolar rupture. A significant proportion of COVID-19 patients with acute respiratory distress syndrome (ARDS) will require mechanical ventilation. We present 2 interesting cases that demonstrate the possibility of COVID-19-associated ARDS manifesting with pulmonary barotrauma at acceptable ventilatory pressures. CASE REPORT The first patient was a 71-year-old man who was intubated and placed on mechanical ventilation due to hypoxemic respiratory failure from SARS-CoV-2 infection. His partial pressure of O2 to fraction of inspired oxygen ratio (PaO2/FiO2) was 156. He developed subcutaneous emphysema (SE) and pneumomediastinum on day 5 of mechanical ventilation at ventilatory settings of positive end-expiratory pressure (PEEP) ≤15 cmH₂O, plateau pressure (Pplat) ≤25 cmH₂O and pulmonary inspiratory pressure (PIP) ≤30 cmH₂O. He was managed with 'blow-hole' incisions, with subsequent clinical resolution of subcutaneous emphysema. The second patient was a 58-year-old woman who was also mechanically ventilated due to hypoxemic respiratory failure from COVID-19, with PaO2/FiO2 of 81. She developed extensive SE with pneumomediastinum and pneumothorax while on mechanical ventilation settings PEEP 13 cmH₂O and PIP 28 cmH₂O, Pplat 18 cmH₂O, and FiO2 90%. SE was managed with blow-hole incisions and pneumothorax with chest tube. CONCLUSIONS Clinicians should be aware of pulmonary barotrauma as a possible complication of COVID-19 pulmonary disease, even at low ventilatory pressures.