• Air leak
• COVID-19
• ECMO Macklin effect
• Extracorporeal membrane oxygenation
• Mechanical power
• Pneumomediastinum

• Computer-aided diagnosis
• Computerized tomography imaging
• Deep neural networks
• Multimodal analysis
• Omicron variant

• COVID-19
• polymerase chain reaction
• spontaneous pneumothorax.

• COVID-19
• Pneumothorax
• SARS-CoV-2
• pneumomediastinum
• subcutaneous emphysema

• Adult
• Humans
• Male
• Female
• COVID-19/complications
• COVID-19/epidemiology
• SARS-CoV-2
• Mediastinal Emphysema/epidemiology
• Mediastinal Emphysema/etiology
• Mediastinal Emphysema/therapy
• Pneumothorax/epidemiology
• Pneumothorax/etiology
• Pneumothorax/therapy
• Incidence
• Retrospective Studies
• Subcutaneous Emphysema/etiology
• Subcutaneous Emphysema/complications
• Adrenal Cortex Hormones

• COVID‐19
• bilateral spontaneous pneumothorax
• spontaneous pneumothorax

• bullous lung disease
• coronavirus disease 2019
• covid-19
• raoultella
• raoultella planticola
• rare cause of infection
• superinfection

• COVID-19
• Drugs and medicines
• Pneumomediastinum
• Respiratory system

• COVID
• disease management
• emergency visits
• primary care
• smoking

• Aged
• Humans
• Male
• COVID-19/complications
• Dyspnea
• Hospitalization
• Pneumothorax/etiology
• Pneumothorax/therapy
• Pulmonary Disease, Chronic Obstructive

• COVID-19
• Omicron
• adolescent
• mediastinal emphysema
• severe pneumonia

• National Natural Science Foundation of China

• covid-19
• noninvasive ventilation
• pneumomediastinum
• positive-pressure ventilation

• Humans
• COVID-19/complications
• COVID-19/epidemiology
• COVID-19/therapy
• Mediastinal Emphysema/diagnostic imaging
• Mediastinal Emphysema/epidemiology
• Mediastinal Emphysema/etiology
• Incidence
• Respiratory Distress Syndrome/complications
• Respiration, Artificial/adverse effects

COVID-19 pneumonia is responsible for the latest pandemics. Chest computed tomography (CT) scan is known to be an essential tool for diagnosis of COVID-19. In this research, the relationship between on-admission chest CT severity score, capillary blood oxygen saturation level, and laboratory inflammatory markers results in patients with SARS-COV-2 pneumonia was investigated.

This prospective analytical study was conducted in COVID-19 isolation unit, Zagazig University Hospitals, from 1st to end of April 2021. Adult patients with COVID-19 infection were included. Chest CT scan was performed for all patients, and CT severity score was computed. The initial capillary oxygen saturation was also assessed at the time of admission. The information was gathered and analyzed.

A total number of 305 COVID-19 patients were involved in the study with the following data: age, gender, presence of co morbidities, capillary blood oxygen saturation, laboratory tests including absolute lymphocytic count, CRP, D-dimer and ferritin levels, as well as chest CT severity score. Based on chest CT severity score, we found that 110 cases (36.1%) were mild, 163 cases (53.4%) were moderate, and 32 cases (10.5%) were severe, with significant male predominance among moderate and severe cases. The initial measurements of blood oxygen saturation values revealed that mean blood oxygen saturation was 95.6% among mild to moderate cases and 85.4% among severe cases. Furthermore, there was a high statistically significant negative correlation between chest CT severity score and absolute lymphocytic count of studied cases, while there was a statistically significant positive correlation with D-dimer, CRP and ferritin levels.

CT scans can help clinicians in developing a management strategy and serve as a predictor of illness severity and possible outcomes. In individuals with COVID-19 infection, the severity of a chest CT scan is positively correlated to inflammatory markers and oxygen demand.

• Pre-existing diffuse lung pathology
• barotrauma
• pneumomediastinum
• pneumothorax (PTX)

• coronavirus disease
• coronavirus disease 2019
• pneumomediastinum
• pneumothorax
• prediction model

To investigate the incidence, risk factors, and outcomes of barotrauma (pneumomediastinum and subcutaneous emphysema) in mechanically ventilated COVID-19 patients. To describe the chest radiography patterns of barotrauma and understand the development in relation to mechanical ventilation and patient mortality.

We performed a retrospective study of 363 patients with COVID-19 from March 1 to April 8, 2020. Primary outcomes were pneumomediastinum or subcutaneous emphysema with or without pneumothorax, pneumoperitoneum, or pneumoretroperitoneum. The secondary outcomes were length of intubation and death. In patients with pneumomediastinum and/or subcutaneous emphysema, we conducted an imaging review to determine the timeline of barotrauma development.

Forty three out of 363 (12%) patients developed barotrauma radiographically. The median time to development of either pneumomediastinum or subcutaneous emphysema was 2 days (IQR 1.0–4.5) after intubation and the median time to pneumothorax was 7 days (IQR 2.0–10.0). The overall incidence of pneumothorax was 28/363 (8%) with an incidence of 17/43 (40%) in the barotrauma cohort and 11/320 (3%) in those without barotrauma (p ≤ 0.001). In total, 257/363 (71%) patients died with an increase in mortality in those with barotrauma 33/43 (77%) vs. 224/320 (70%). When adjusting for covariates, barotrauma was associated with increased odds of death (OR 2.99, 95% CI 1.25–7.17).

Barotrauma is a frequent complication of mechanically ventilated COVID-19 patients. In comparison to intubated COVID-19 patients without barotrauma, there is a higher rate of pneumothorax and an increased risk of death.

• ARDS
• COVID-19
• Pneumothorax
• Pulmonary/critical care

• UL1 TR002384 NCATS NIH HHS

En la actualidad la enfermedad por coronavirus 2019 es un problema de salud pública que ha causado más de 100.000 muertes en Colombia y alrededor de 4,13 millones de muertes en todo el mundo. El síndrome de distrés respiratorio agudo secundario a esta infección viral, puede llevar a una serie de complicaciones como el neumomediastino; este es poco frecuente pero potencialmente mortal y se encuentra relacionado con la ventilación mecánica. Presentamos una serie de casos de 10 pacientes que ingresaron en la Unidad de Cuidados Intensivos con requerimiento de ventilación mecánica invasiva y que desarrollaron neumomediastino. La serie de casos más grande reportada hasta el momento.

While we are still learning about COVID-19 affecting people, older persons and persons with underlying diseases such as high blood pressure, heart disease, and diabetes mellitus (DM) appear to develop serious illness and more complications often than others. In this report, we presented a patient with spontaneous pneumomediastinum after COVID-19. The patient was a 61-year-old man with a history of DM, hypertension, and heart failure, who has been infected with COVID-19. The patient was diagnosed with COVID-19 based on RT-PCR analysis of nasopharyngeal samples, and chest X-ray showed patchy infiltration upper and lower lobes bilaterally. By day 4, imaging was repeated, performed due to exacerbation of pleuritic chest pain, decreased O₂ saturation (80%), and coughing that revealed multiple ground-glass opacities bilaterally, and interlobular septal thickening with emphysema in most of the left upper lobe and a small part of right upper lobe which led to severe spontaneous left pneumomediastinum and parenchymal consolidation was also observed. The combination of a chest tube, antibiotics (vancomycin 1 gr/bid and meropenem 1 g/bid), and antiviral (hydroxychloroquine 200 mg/bid and atazanavir 300 mg/daily) was prescribed, and continued treatment with antiviral and appropriate care for pneumomediastinum was successful. Spontaneous pneumomediastinum in the context of COVID-19 should be considered as a prognostic factor in favor of worsening diseases.

• COVID-19
• Intubation
• Length of stay
• Pneumothorax
• SARS-CoV-2

• Adult
• Aged
• COVID-19/complications
• COVID-19/epidemiology
• Cross-Sectional Studies
• Female
• Humans
• Incidence
• Male
• Middle Aged
• Respiratory Distress Syndrome
• Retrospective Studies
• SARS-CoV-2

• UL1 TR002384 NCATS NIH HHS

There is limited information on clinical profile and outcomes of patients on mechanical ventilation (MV) who developed pulmonary barotrauma (PBT) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

In a retrospective observational study, all SARS-CoV-2 pneumonia patients admitted from March 28, 2020, to August 31, 2020, at Sir HN Reliance Foundation Hospital and Research Center and Seven Hills Hospital (Reliance Facility), Mumbai, India, of 18 years and above on MV and developed PBT, were included.

A total of 14 SARS-CoV-2 patients of 45 on MV (31.0%) developed PBT of 1,029 hospitalized. All patients were male and divided as per admission into PaO₂/FiO₂ (P/F) ≤100 (median 80) and P/F >100 (median 222) group. Pneumothorax developed in seven and six cases of P/F ≤100 and P/F >100 groups, respectively. Three patients in each group developed subcutaneous emphysema, while four developed pneumomediastinum in P/F >100 group. Twelve patients (7, P/F ≤100, and 5, P/F >100) were on invasive, while two (P/F >100) were on noninvasive MV. The mean P/F on the day of PBT was reduced by 27.5 and 65.3%, while peak inspiratory pressure was elevated with a median of 36 and 28 cm H₂O in P/F ≤100 and P/F >100 groups, respectively. The median highest tidal volume (420 mL), positive-end expiratory pressure (8 vs 6 cm H₂O) on the day of PBT, and length of hospital stay (11 vs 25 days) did not differ between two groups. Survival was 28.6% (4/14).

SARS-CoV-2 patients requiring MV with PBT had poor outcomes. Clinicians should be vigilant about the diagnosis of PBT.

Kargirwar KV, Rathod D, Kumar V, Patel M, Shah M, Choudhury H, et al. Clinical Profile of Patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection Developing Pulmonary Barotrauma on Mechanical Ventilation. Indian J Crit Care Med 2022;26(5):613–618.

• COVID‐19
• coronavirus
• pneumomediastinum
• pneumonia
• spontaneous pneumothorax

• Coronavirus disease 2019
• Covid-19 pneumonia
• Pulmonary embolism
• Severe acute respiratory syndrome coronavirus 2
• Spontaneous pneumomediastinum
• Venous thromboembolism

Pneumothorax and pneumomediastinum are life-threatening conditions especially in critically ill patients. One of the most common situations in which they occur is prolonged invasive and non-invasive mechanical ventilation with high end-expiratory pressure. Probably due to the high number of patients with SARS-CoV-2 respiratory infection being treated with mechanical ventilation, increasing number of pulmonary barotrauma cases have been reported.

• COVID-19
• Pandemic
• Pneumomediastinum
• Pneumothorax
• SARS-CoV-2

Coronavirus illness 2019, commonly referred to as COVID-19, is a highly infectious disease brought on by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 was declared a universal pandemic in March 2020 by the World Health Organization and is a severe health issue with unprecedented morbidity and mortality rates. Both surgical and mediastinal emphysema have been seen in cases of critically ill COVID-19 patients in several hospitals in the Eastern Province of Saudi Arabia.

This was a retrospective, cross-sectional, multicentric study involving several hospitals in the Saudi Arabian Eastern Province. Data were collected from intensive care units (ICUs) in these hospitals from March 2 to August 2, 2020. The inclusion criteria consisted of all patients who tested positive for SARS-CoV-2 and were admitted to a critical care unit.

Thirty patients required thoracic consultation and management, including 26 males (81.3%) and 4 females (12.5%) (1:0.15) who developed surgical and mediastinal emphysema requiring thoracic surgery intervention. Most of the patients were on high ventilation settings, and the mean duration of ventilator support was 16.50 ± 13.98 days. Two patients (6.3%) required reintubation. The median positive end-expiratory pressure (PEEP) was 12 ± 2.80 cmH₂O with a median FiO2 of 70% ± 19.73. On average, thoracic complications occurred on day 3 (±6.29 days) postintubation. Ten patients (33.33%) experienced a pneumothorax associated with surgical emphysema (SE), 1 patient (3.33%) presented with only mediastinal emphysema; 17 patients (56.66%) with only SE, and 1 (3.33%) had mediastinal emphysema associated with SE. We noted a correlation between the duration of ventilator support, the length of ICU stay (P < 0.001), and the total length of stay (LOS) in the hospital (P < 0.001). Total length of hospital stay showed significant association with the onset of complications (P = 0.045) and outcomes (P = 0.006). A significant association between PEEP and the duration of ventilator support was also evident with a P value = 0.009 and the onset of complications (P = 0.043). In addition, we found a significant association between the group with pneumothorax in combination with SE, and their outcomes, with a P = 0.002.

Surgical and mediastinal emphysema in the critically ill patients are usually attributed to barotrauma and high ventilations settings. During COVID-19 pandemic, these entities were seen and the pathogenesis was revisited and some attributed its presence to the disease process and destruction on lung parenchyma. The associated with extended LOS and delayed recovery in addition to poor prognosis were seen. Their presence is an indicator to higher morbidity and mortality.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus, represents an unprecedented global threat. We report a 78-year-old male patient who presented to the Emergency Department at a tertiary care hospital in Muscat, Oman, in June 2020 with a one-day history of right chest pain and severe breathlessness. The patient was an ex-smoker and known to have idiopathic pulmonary fibrosis (IPF) with two previous pneumothoraces in the left lung. On presentation, the patient was breathless with an oxygen saturation of 90% on room air. Chest X-ray demonstrated bilateral lung infiltrates and right-sided pneumothorax. The patient tested positive for SARS CoV 2. A chest drain was placed which resulted in good resolution of the pneumothorax. The patient’s condition improved remarkably and he was discharged after 17 days of hospitalisation. To the best of the authors’ knowledge, this was the first case of pneumothorax reported in a patient infected with COVID-19 who was known to have underlying IPF.

• COVID-19
• Case Report
• Oman
• Oxygen
• Pleurodesis
• Pulmonary Fibrosis
• SARS Coronavirus
• Spontaneous Pneumothorax

• Coronavirus disease 2019
• Pneumomediastinum

• Adolescent
• Adult
• COVID-19/complications
• Child
• Female
• Humans
• Male
• Mediastinal Emphysema/diagnostic imaging
• Mediastinal Emphysema/epidemiology
• Mediastinal Emphysema/etiology
• Middle Aged
• Pandemics
• Risk Factors
• SARS-CoV-2
• Young Adult

We encountered the novel coronavirus infection as a pandemic in 2020. The infection started in Wuhan, China, and spread rapidly all over the world. CT scan has been used as an important diagnostic method in the detection of suspicious patients. One of the uncommon complications of coronavirus disease 2019 (COVID-19) is pneumothorax.

A 47-year-old smoker male with COVID-19 diagnosis, good general condition and no respiratory complaint, complicated by pneumothorax. He refused hospitalization. After educating him about the red flags and quarantine protocols, he continued treatment at home .Cap amoxicillin/clavulanic acid 625mg was prescribed for one week. A follow-up CT represented only small involvement of lungs. Pneumothorax was resolved spontaneously without any medical intervention and hospitalization. O₂ saturation was in normal range an there was no dry cough anymore.

According to our clinical experience, pneumothorax is resolved spontaneously in a COVID-19 case. Considering general status and hemodynamic stability, it is suggested to reduce invasive interventions in COVID-19 cases with pneumothorax.

• COVID-19
• CT scan
• Iran
• Pneumothorax
• Radiology

Spontaneous pneumomediastinum (SPM) is a rare condition defined by the presence of air in the mediastinum in the absence of traumatic or iatrogenic injury. Although the imaging findings and complications of SARS-CoV-2 infection have been reported many times, there are few reports of the prevalence and outcomes of patients with SPM.

In this paper, we aimed to illustrate the different manifestations, management, and outcome of three cases of SPM in COVID-19 patients and provide an extensive review available literature.

Detailed report of patients' demographics, clinical presentation, management, and outcome of three cases of COVID-19 induced SPM seen in our institution was provided. Additionally, literature search was employed through March 2021 using Pubmed and Google scholar databases where a total of 22 articles consisting of 35 patients were included.

Statistical analysis of the reviewed articles showed that SPM in COVID-19 occurs in patients with a mean age of 55.6 ± 16.7 years. Furthermore, 80% of the 35 patients are males and almost 60% have comorbidities. Intriguingly, SPM in COVID-19 is associated with a 28.5% mortality rate. These findings are consistent with our case series and are different from previous reports of SPM in non-COVID-19 cases where it most commonly occurs in younger individuals and has a self-limiting course with a good outcome.

Therefore, SPM in COVID-19 patients occurs in older patients and is potentially associated with a higher mortality rate. Further studies are necessary to assess its role as a prognostic marker of poor outcome.

• COVID-19
• Prognostic factor
• SARS-CoV-2
• Spontaneous pneumomediastinum

• COVID-19
• CT
• Chest
• Pneumothorax

The coronavirus disease 2019 (COVID-19) pandemic has stretched our healthcare system to the brink, highlighting the importance of efficient resource utilization without compromising healthcare provider safety. While advanced imaging is a great resource for diagnostic purposes, the risk of contamination and infection transmission is high and requires extensive logistical planning for intrahospital patient transport, healthcare provider safety, and post-imaging decontamination. This dilemma has necessitated the transition to more bedside imaging. More so than ever, during the current pandemic, the clinical utility and importance of point-of-care ultrasound (POCUS) cannot be overstressed. It allows for safe and efficient beside procedural guidance and provides front line providers with valuable diagnostic information that can be acted upon in real-time for immediate clinical decision-making. The authors have been routinely using POCUS for the management of COVID-19 patients both in the emergency department and in intensive care units turned into “COVID-units.” In this article, we review the nuances of using POCUS in a pandemic situation and maximizing diagnostic output from this bedside technology. Additionally, we review various methods and diagnostic uses of POCUS which can replace conventional imaging and bridge current literature and common clinical practices in critically ill patients. We discuss practical guidance and pertinent review of the literature for the most relevant procedural and diagnostic guidance of respiratory illness, hemodynamic decompensation, renal failure, and gastrointestinal disorders experienced by many patients admitted to COVID-units.

• COVID-19
• SARS-CoV-2
• Point-of-care ultrasound
• COVID-intensive care units
• COVID-unit
• Critical care
• Decontamination
• Pandemic
• Imaging in COVID-19
• Point-of-care ultrasound in a pandemic

Cases of spontaneous pneumothorax have been described in patients suffering from coronavirus disease 2019 (COVID-19) pneumonia. The aim of this study is to systematically review all the cases of spontaneous pneumothorax that occurred in healthy patients with no underlying lung disease and who did not receive invasive mechanical ventilation.

A PubMed research was conducted. The following data were collected: age, sex, side of the pneumothorax, smoking habit, time form onset of symptoms to the diagnosis of pneumothorax, the development of new bullous lesions on computed tomography and the type of treatment. In order to analyze the most homogeneous population possible, intubated patients were deliberately excluded. In total, 44 cases of spontaneous pneumothorax in otherwise healthy patients were taken into account. Since the available data were extracted from small observational studies, no particular bias risk assessment was performed. Descriptive statistics were used to synthesize results.

There were 37 male (84.1%) and 6 female (13.6%) patients. The majority of patients (66%) were treated only by chest tube thoracostomy, which most of the times resulted in a complete resolution of the pneumothorax. Simple surveillance was applied in 10 cases. Three patients underwent minimally invasive surgery. In 14 cases (31.8%) air-filled lesions were detected on imaging. Eleven patients received corticosteroids during their hospital stay. In the majority of cases (86.3%) the pneumothorax was resolved.

Even if the level of evidence, derived from case reports and small case series is low, the existence of a true secondary spontaneous pneumothorax due to SARS-CoV-2 should be recognized. Imaging techniques should be repeated throughout the clinical course of the patients in order to detect newly developed pulmonary complications. Surgical treatment is feasible and patients whose general condition permits, should be offered surgery according to the existing guidelines regarding spontaneous pneumothorax. National registries and databases are necessary in order to better understand the pathogenesis and complications of this novel entity.

• Coronavirus disease 2019 (COVID-19)
• pneumonia
• pneumothorax

Pneumomediastinum and subcutaneous emphysema have been reported in COVID-19 around the world except for Nepal. We report a case of a 44-year-old male infected with COVID-19 who developed pneumomediastinum and subcutaneous emphysema during his eighth day of intubation at the hospital. He was managed with remdesivir, antibiotics, mechanical ventilation, steroid, and heparin following which he recovered well. Barotrauma-related complications are common in COVID-19 and our case highlights the importance of conservative management for such complications and the rarity of such conditions in Nepal.

• covid-19
• mediastinal emphysema
• nepal
• pneumothorax
• respiratory distress syndrome

• Coronavirus
• Pneumomediastinum
• Pneumothorax
• SARS-CoV‑2
• Soft tissue emphysema

The incidence of secondary coinfections particularly fungal infections among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not well described. Little is known of the complications that could be encountered in such conditions.

A 50-year-old Hispanic male who was a prior smoker presented with shortness of breath. He was diagnosed with SARS-CoV-2. He improved and was discharged with home oxygen. A month later, he presented with sudden onset cough and shortness of breath. Chest X-ray showed development of right-sided tension pneumothorax, right pleural effusion and an air-filled cystic structure. Computed tomography thorax showed findings suggestive of pulmonary coccidioidomycosis. Coccidioides antigen was positive, and fluconazole was initiated. For pneumothorax, a pigtail catheter was placed. The pigtail chest tube was later switched to water seal, unfortunately, the pneumothorax re-expanded. Another attempt to transition chest tube to water seal was unsuccessful. Pigtail chest tube was then swapped to 32-Fr chest tube and chemical pleurodesis was performed. This was later transitioned successfully to water seal and finally removed. He was discharged on a four-week oral course of fluconazole 400 mg and was to follow up closely as an outpatient for continued monitoring.

Pneumothorax is associated with a worse prognosis, especially with comorbidities such as diabetes, immunosuppression and malignancy. Suspicion for concomitant fungal infection in such patients should be high and would necessitate further investigation.

• SARS-CoV-2
• COVID-19
• Coccidioidomycosis
• Co-infection
• Fungal infection
• Tension pneumothorax
• Refractory pneumothorax
• Case report
• Literature review

• covid-19
• pleurodesis
• pneumonia
• pneumothorax
• recurrent pneumothorax

• COVID-19
• Pneumomediastinum
• Pneumothorax
• SARS-CoV-2

Coronavirus disease 2019 (COVID-19) is an infectious disease primarily affecting the lungs with a spectrum of post-viral complications. There are well-described examples of pneumonia, empyema, pneumomediastinum, and spontaneous pneumothorax cases following COVID-19 infection within the literature. However, there is insufficient evidence implicating the cause of spontaneous pneumothorax in COVID-19 recovered patients. We present a previously infected COVID-19 patient who developed a secondary spontaneous pneumothorax two weeks after recovering. A review of the literature for similar cases was limited and therefore includes a summary of recommendations. Overall, the literature establishes that pneumothorax can occur during different phases of COVID-19 in patients without a history of pulmonary disease or barotrauma and is not necessarily associated with the severity of the viral infection. As in the case of our patient, the culmination of chronic inflammatory changes and an acute exacerbation from COVID-19 further predisposed him to a secondary spontaneous pneumothorax. In summary, all cases of recovered COVID-19 patients should maintain close follow-up with their physician and seek medical attention if acute respiratory symptoms develop.

• covid-19
• covid-19 pneumonia
• pneumonia
• secondary pneumothorax
• spontaneous pneumothorax

• COVID-19
• pleura
• pleural effusion
• pneumothorax
• radiology

• COVID-19
• emergency medicine
• pneumothorax
• radiology

Background: Pneumomediastinum, subcutaneous emphysema and pneumothorax are not rarely observed during the COVID-19 pandemic. Such complications can worsen gas exchange and the overall prognosis in critical patients. The aim of this study is to investigate what predisposing factors are related to pneumomediastinum and pneumothorax in SARS-CoV2-Acute Respiratory Distress Syndrome (ARDS), what symptoms may predict a severe and potentially fatal complication and what therapeutical approach may provide a better outcome. Methods: In this single center cohort study, we recorded data from 45 critically ill COVID-19 patients who developed one or more complicating events among pneumomediastinum, subcutaneous emphysema and pneumothorax. All patients showed ARDS and underwent non-invasive ventilation (NIV) at baseline. Patients with mild to moderate ARDS and pneumomediastinum/pneumothorax (n = 25) received High Flow Nasal Cannula (HFNC), while patients with severe ARDS and pneumomediastinum/pneumothorax underwent HFNC (n = 10) or invasive mechanical ventilation (IMV) (n = 10). Results: Pneumomediastinum/pneumothorax developed in 10.5% of subjects affected by SARS-coV2-ARDS. Dyspnea affected 40% and cough affected 37% of subjects. High resolution computed tomography of the chest showed bilateral diffuse ground glass opacities (GGO) in 100% of subjects. Traction bronchiolectasis, reticulation, crazy paving and distortion were observed in 64%. Furthermore, 36% showed subcutaneous emphysema. Non-severe ARDS cases received HFNC, and 76% patients recovered from pneumomediastinum/pneumothorax over a median follow up of 5 days. Among severe ARDS cases the recovery rate of pneumomediastinum/pneumothorax was 70% with the HFNC approach, and 10% with IMV. Conclusion: HFNC is a safe and effective ventilatory approach for critical COVID-19 and has a positive role in associated complications such as pneumomediastinum and pneumothorax.

• ARDS
• P-SILI
• critical COVID-19
• mechanical ventilation
• non-invasive ventilation

Severe acute respiratory syndrome coronavirus 2 can cause pulmonary complications, such as increased risk of barotrauma (BT), but its prevalence and risk factors are not known. In this case series, the course of BT and its related risk factors were discussed in patients with COVID-19 who were admitted to the intensive care unit. Medical records of the patients with COVID-19 and BT and hospitalized in the intensive care unit for 5 months were extracted. The course of BT and its possible associated risk factors are descriptively presented. Among 103 patients with COVID-19 who were intubated, 13 patients (12.6%) had BT. One patient developed BT before intubation. All patients with BT were male. Half of them developed BT in the first 5 days of intubation. Eight patients (61.53%) had a positive culture for Klebsiella pneumoniae. Nine patients (69.9%) died. High positive end-expiratory pressure, coinfection with bacterial pneumonia, and history of lung disease may affect BT incidence. The treatment team should increase their upervision on the ventilator setting, especially in the first week of intubation.

The presenting symptoms and features of COVID-19 are non-specific and may be extrapulmonary complications such as thrombotic disorders but also pneumothorax, pneumomediastinum and subcutaneous emphysema; which are well-known complications of mechanical ventilation. Nevertheless, pneumothorax and/or pneumomediastinum, could complicate the course of a COVID-19 disease even in the absence of barotrauma involved. Herein, we report the case of a 55-year-old man with a previous history of erythroblastopenia due to thymoma admitted for COVID-19-related acute respiratory distress syndrome (ARDS) who simultaneously developed spontaneous tension pneumothorax, pneumomediastinum, subcutaneous emphysema and acute bilateral pulmonary embolism as presenting features of COVID-19 while on high-flow nasal cannula. This rare case highlights the importance of screening for other coexisting alternative diagnoses at the initial presentation of a patient suspected of COVID-19.

• COVID-19
• case report
• pneumomediastinum
• spontaneous tension pneumothorax
• subcutaneous emphysema

• COVID‐19
• echocardiography COVID
• esophageal perforation
• transesophageal ultrasound

Iatrogenic pneumothoracis, barotraumas, and tracheoesophageal fistulae, especially after prolonged intubation, and tracheal stenosis are all entities involving thoracic surgeons' consultation and management. With the surge of COVID-19 cases particularly in the critical care settings, various types of complications have been observed that require intervention from thoracic surgeons.

A retrospective study was conducted in an academic healthcare institute in the Eastern Province of Saudi Arabia. We included all COVID-19 cases admitted to ICU in the period between March 15, 2020, and August 15, 2020, requiring thoracic surgery consultation and management. Non-COVID-19 critical cases and iatrogenic pneumothorax were excluded.

Of 122 patients who were admitted to ICU with COVID-19, 18 patients (14.75%) required thoracic surgery consultation and management. We discovered a significant association between the outcomes and reintubation rates and the rate of pneumothorax occurrence. The survival analysis showed improvement in patients who had thoracostomy tube insertion as a management than the group who were treated conservatively. On the other hand, there was a significant difference between the COVID ICU group who had thoracic complication and those who did not regarding the length of hospital stay.

Noniatrogenic pneumothorax, subcutaneous emphysema, and mediastinal emphysema are well-known thoracic entities, but their presence in the context of COVID-19 disease is a harbinger for worse prognosis and outcomes. The presence of pneumothorax may be associated with better prognosis and outcome compared to surgical and mediastinal emphysema.

The typical CT manifestations of COVID-19 pneumonia include ground-glass opacity (GGO) with or without consolidation and superimposed interlobular septal thickening. These are often rounded in morphology and frequently bilateral, multilobar, posterior, peripheral, and basilar in distribution. The various atypical CT features of COVID-19 are seldom described in the literature. The study aims to enumerate the atypical pulmonary CT features in patients with COVID-19 pneumonia in correlation with the disease severity.

A total of 298 confirmed cases of COVID-19 pneumonia with positive reverse transcription polymerase chain reaction (RT-PCR) who underwent chest CT scans were retrospectively evaluated. The cohort included 234 (78.5%) men and 64 (21.5%) women and the mean age was 53.48 ± 15.74 years. The most common presenting symptoms were fever [n = 197 (66.1%)] and cough [n = 139 (46.6%)]. Out of 298 cases of COVID-19 pneumonia, 218 cases (73.1%) showed typical CT features while 63 cases (21.1%) showed atypical CT features with concurrent classical findings and the remaining 17 cases (5.8%) were normal. Among the atypical CT features, the most common was pulmonary cysts [n = 27 (9%)]. The other features in the order of frequency included pleural effusion [n = 17 (5.7%)], nodules [n = 13 (4.3%)], bull’s eye/target sign[n = 4 (1.3%)], cavitation [n = 3 (1.0%)], spontaneous pneumothorax [n = 2 (0.6%)], hilar lymphadenopathy [n = 2 (0.6%)], spontaneous pneumo-mediastinum with subcutaneous emphysema [n = 1 (0.3%)], Halo sign [n = 1 (0.3%)], empyema [n = 1 (0.3%)] and necrotizing pneumonia with abscess [n = 1 (0.3%)].

CT imaging features of COVID-19 pneumonia while in a vast majority of cases is classical, atypical diverse patterns are also encountered. A comprehensive knowledge of various atypical presentations on imaging plays an important role in the early diagnosis and management of COVID-19.