Housman Brian, Jacobi Adam, Carollo Andrea, Nobel Tamar, Eber Corey, Acquah Samuel, Powell Charles, Kaufman Andrew, Lee Dong-Seok, Nicastri Daniel, Hakami Ardeshir, Song Kimberly, Kohli-Seth Roopa, Flores Raja
Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.
Ann Transl Med. 2020 Dec;8(23):1575. doi: 10.21037/atm-20-3907.
COVID-19 patients requiring mechanical ventilation may develop significant pneumomediastinum and sub-cutaneous emphysema without associated pneumothorax (SWAP). Prophylactic chest tube placement or sub-fascial "blowholes" are usually recommended to prevent tension pneumothorax and clinical decline. Risk of iatrogenic lung injury and release of virus into the environment is high. Incidence and conservative management data of such barotraumatic complications during the COVID-19 pandemic are lacking.
All patients with mediastinal air and SWAP evaluated by the department of Thoracic Surgery at the Mount Sinai Hospital between March 30 and April 10, 2020 were identified. All patients without pneumothorax were treated conservatively with daily chest x-ray and observation. Three patients had prophylactic chest tube placement prior to the study period without thoracic surgery consultation.
There were 29 cases of mediastinal air with SWAP out of 171 COVID positive intubated patients (17.0%) who were treated conservatively. Patients were intubated for an average of 2.4 days before SWAP was identified. 12 patients (41%) had improvement or resolution without intervention. Two patients progressed to pneumothorax 3 and 8 days following initial presentation. Both had chest tubes placed without incident before there were any changes in oxygenation, hemodynamics, supportive medications, or ventilator settings. There were 3 patients who had percutaneous tubes placed before the study period all of whom had significant worsening of their sub-cutaneous air and air leak.
Conservative management of massive sub-cutaneous emphysema without pneumothorax in COVID-19 patients is safe and limits viral exposure to healthcare workers. Placement of chest tubes is discouraged unless a definite sizable pneumothorax develops.
需要机械通气的新冠病毒肺炎（COVID-19）患者可能会出现严重的纵隔气肿和皮下气肿，且无气胸相关表现（SWAP）。通常建议预防性放置胸管或进行筋膜下“通气孔”操作以预防张力性气胸和病情恶化。医源性肺损伤及病毒释放到环境中的风险很高。目前缺乏COVID-19大流行期间此类气压伤并发症的发病率及保守治疗数据。
确定了2020年3月30日至4月10日期间在西奈山医院胸外科评估的所有患有纵隔积气和SWAP的患者。所有无气胸的患者均接受保守治疗，每日进行胸部X光检查并观察。有3例患者在研究期之前未咨询胸外科就进行了预防性胸管放置。
171例接受保守治疗的COVID阳性插管患者中有29例出现纵隔积气伴SWAP（17.0%）。患者在SWAP被发现前平均插管2.4天。12例患者（41%）未经干预病情得到改善或缓解。2例患者在初次就诊后3天和8天进展为气胸。两人在氧合、血流动力学、支持性药物或呼吸机设置没有任何变化之前顺利放置了胸管。有3例患者在研究期之前进行了经皮置管，所有患者的皮下气肿和漏气均显著加重。
对COVID-19患者无气胸的大量皮下气肿进行保守治疗是安全的，并限制了医护人员接触病毒。除非出现明确的较大气胸，否则不建议放置胸管。
