Pneumomediastinum in COVID-19: a phenotype of severe COVID-19 pneumonitis? The results of the United Kingdom (POETIC) survey.
Melhorn J., Achaiah A., Conway FM., Thompson EMF., Skyllberg EW., Durrant J., Hasan NA., Madani Y., Naran P., Vijayakumar B., Tate MJ., Trevelyan GE., Zaki I., Doig CA., Lynch G., Warwick G., Aujayeb A., Jackson KA., Iftikhar H., Noble JH., Ng AYKC., Nugent M., Evans PJ., Hastings RA., Bellenberg HR., Lawrence H., Saville RL., Johl NT., Grey AN., Ellis HC., Chen C., Jones TL., Maddekar N., Khan SL., Muhammad AI., Ghani H., Myint YMM., Rafique C., Pippard BJ., Irving BRH., Ali F., Asimba VH., Azam A., Barton EC., Bhatnagar M., Blackburn MP., Millington KJ., Budhram NJ., Bunclark KL., Sapkal TP., Dixon G., Harries AJE., Ijaz M., Karunanithi V., Naik S., Khan MA., Savlani K., Kumar V., Gallego BL., Mahdi NA., Morgan C., Patel N., Rowlands EW., Steward MS., Thorley RS., Wollerton RL., Ullah S., Smith DM., Lason W., Rostron AJ., Rahman NM., Hallifax RJ.
BackgroundThere is an emerging understanding that coronavirus disease 2019 (COVID-19) is associated with increased incidence of pneumomediastinum. We aimed to determine its incidence among patients hospitalised with COVID-19 in the United Kingdom and describe factors associated with outcome.MethodsA structured survey of pneumomediastinum and its incidence was conducted from September 2020 to February 2021. United Kingdom-wide participation was solicited via respiratory research networks. Identified patients had SARS-CoV-2 infection and radiologically proven pneumomediastinum. The primary outcomes were to determine incidence of pneumomediastinum in COVID-19 and to investigate risk factors associated with patient mortality.Results377 cases of pneumomediastinum in COVID-19 were identified from 58 484 inpatients with COVID-19 at 53 hospitals during the study period, giving an incidence of 0.64%. Overall 120-day mortality in COVID-19 pneumomediastinum was 195/377 (51.7%). Pneumomediastinum in COVID-19 was associated with high rates of mechanical ventilation. 172/377 patients (45.6%) were mechanically ventilated at the point of diagnosis. Mechanical ventilation was the most important predictor of mortality in COVID-19 pneumomediastinum at the time of diagnosis and thereafter (p<0.001) along with increasing age (p<0.01) and diabetes mellitus (p=0.08). Switching patients from continuous positive airways pressure support to oxygen or high flow nasal oxygen after the diagnosis of pneumomediastinum was not associated with difference in mortality.ConclusionsPneumomediastinum appears to be a marker of severe COVID-19 pneumonitis. The majority of patients in whom pneumomediastinum was identified had not been mechanically ventilated at the point of diagnosis.