Ashley Gutierrez Santana, MD
Resident Physician
University of Tennessee Graduate School of Medicin
Knoxville, Tennessee
Disclosure information not submitted.
Michael Gerbo, MD, MBA
Resident Physician
University of Tennessee Medical Center Knoxville
Knoxville, Tennessee, United States
Disclosure information not submitted.
Samuel Treat, MD
Internal Medicine Resident
University of Tennessee Medical Center
Knoxville, Tennessee, United States
Disclosure information not submitted.
Nishant Sharma, MD
Pulmonology and Critical Care Fellow
n/a, United States
Disclosure information not submitted.
Sean Jordan, MD
Assistant Professor Division of Cardiothoracic Surgery
University of Tennessee Medical Center Knoxville
Knoxville, Tennessee, United States
Disclosure information not submitted.
Tina Dudney, MD, D.ABSDM, FCCP
Chief, Division of Pulmonary Critical Care Medicine
University of Tennessee Medical Center - Knoxville
Knoxville, Tennessee, United States
Disclosure information not submitted.
Title: New Meaning to Chest Tightness: Tension Pneumomediastinum and Bedside Mediastinoscopy In SARS-CoV-2
Case Report Body:
Introduction: Tension pneumomediastinum is a potential life-threatening complication of mechanical ventilation. We present a case of tension pneumomediastinum in a partially vaccinated SARS-CoV-2 patient with mediastinotomy performed at bedside.
Description: A 58-year-old morbidly obese female presented with fever, myalgia, and dyspnea of 96 hours. She was found to be positive for SARS-CoV-2 by respiratory polymerase chain reaction testing (PCR) and admitted for observation. She had received a single dose of the SARS-CoV-2 vaccination approximately 4 weeks prior. Initially treated with remdesivir and dexamethasone, she required increasing levels of supplemental oxygen and ultimately endotracheal intubation and mechanical ventilation on day 7. She was managed with a low tidal volume and high PEEP ventilation strategy in pressure regulated volume control mode with adjunctive epoprostenol. On day three of mechanical ventilation, she exhibited worsening oxygenation despite a PEEP of 12 mm Hg with peak pressure of 36 mm Hg and plateau pressure of 31 mm Hg. She developed subcutaneous emphysema extending from the clavicles to the upper abdomen, with subsequent computed tomography (CT) of the thorax revealing pneumomediastinum with posterior displacement of the heart. Given worsening oxygenation and hemodynamic instability, bedside mediastinotomy was performed via a suprasternal incision with dissection along the anterior trachea into the mediastinum to the level of the brachiocephalic vein followed by placement of a 24 French Blake drain set to -20cmH2O suction via atrium. All feasible efforts were employed to minimize plateau pressure. Although follow-up imaging demonstrated significant improvement of the pneumomediastinum, the patient succumbed to her illness weeks later.
Discussion: Tension pneumomediastinum is a severe complication associated with barotrauma. Pneumomediastinum in ventilated COVID-19 patients has been described. We present this unique case of COVID-associated pneumomediastinum managed by bedside mediastinotomy and placement of a mediastinal drain, which has rarely been reported. It is important to note that barotrauma in this patient occurred despite a generally tolerated plateau pressure of 31 mm Hg, highlighting virus-related alveolar destruction and the predisposition of COVID-19 patients to barotrauma.