Discussion:
The incidence of pneumomediastinum secondary to NIV is low (1). This pathology should be suspected in case of subcutaneous emphysema or dyspneic sensation, mostly if there’s a concomitantly pneumothorax. The risk increases, according to the cause for which mechanical ventilation is required, in the patient exposed it was secondary to an ARDS infection by COVID-19.
Due to the vital risk that pneumomediastinum can produce, especially when accompanied by pneumothorax, it’s important to suspect it early and confirm urgently using imaging techniques. Pneumomediastinum is associated with increased morbidity and mortality, so avoiding it’s decisive.
To prevent it is crucial to carry out protection strategies during ventilation, such as maintaining pressure Plateau < 30cmH2O (only possible in patients with invasive mechanical ventilation) or maintaining reduced tidal volumes (between 6 to 8 mL/kg based on the ideal body weight), or low support pressures (3).
In our patient, COVID-19 positive, even performing mechanical ventilation with protection strategies, such as keeping volumes reduced, and being in CPAP mode at 12 cmH2O, it was produced a pneumomediastinum with its consequent worst outcome (6).
Therefore, in addition to the increased risk of pneumomediastinum due to ARDS caused by the COVID-19 infection, we cannot rule out if this infection may cause respiratory damage that may increase the risk of barotrauma, and if those patients should be closely monitored.
There’re only two reported cases of spontaneous pneumomediastinum in a positive COVID patient, who were not submitted to ventilation (4,5).
We still don’t have enough information available about all the phisiopatology of the coronavirus infection and we will have to wait for more publications and case series studies.