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      Macklin effect on baseline chest CT scan accurately predicts barotrauma in COVID-19 patients


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          To validate the role of Macklin effect on chest CT imaging in predicting subsequent occurrence of pneumomediastinum/pneumothorax (PMD/PNX) in COVID-19 patients.

          Materials and methods

          This is an observational, case-control study. Consecutive COVID-19 patients who underwent chest CT scan at hospital admission during the study time period (October 1st, 2020–April 31st, 2021) were identified. Macklin effect accuracy for prediction of spontaneous barotrauma was measured in terms of sensitivity, specificity, positive (PPV) and negative predictive values (NPV).


          Overall, 981 COVID-19 patients underwent chest CT scan at hospital arrival during the study time period; 698 patients had radiological signs of interstitial pneumonia and were considered for further evaluation. Among these, Macklin effect was found in 33 (4.7%), including all 32 patients who suffered from barotrauma lately during hospital stay (true positive rate: 96.9%); only 1/33 with Macklin effect did not develop barotrauma (false positive rate: 3.1%). No barotrauma event was recorded in patients without Macklin effect on baseline chest CT scan. Macklin effect yielded a sensitivity of 100%(95%CI: 89.1–100), a specificity of 99.85%(95%CI: 99.2–100), a PPV of 96.7%(95%CI: 80.8–99.5), a NPV of 100% and an accuracy of 99.8%(95%CI: 99.2–100) in predicting PMD/PNX, with a mean advance of 3.2 ± 2.5 days. Moreover, all Macklin-positive patients developed ARDS requiring ICU admission and, in 90.1% of cases, invasive mechanical ventilation.


          Macklin effect has high accuracy in predicting PMD/PNX in COVID-19 patients; it is also an excellent predictor of disease severity.

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          Most cited references25

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          Microvascular COVID-19 lung vessels obstructive thromboinflammatory syndrome (MicroCLOTS): an atypical acute respiratory distress syndrome working hypothesis.

          We suggest the use of MicroCLOTS (microvascular COVID-19 lung vessels obstructive thromboinflammatory syndrome) as a new name for severe pulmonary coronavirus disease 2019 (COVID-19). We hypothesise that, in predisposed individuals, alveolar viral damage is followed by an inflammatory reaction and by microvascular pulmonary thrombosis. This progressive endothelial thromboinflammatory syndrome may also involve the microvascular bed of the brain and other vital organs, leading to multiple organ failure and death. Future steps in the understanding of the disease and in the identification of treatments may benefit from this definition and hypothesised sequence of events.
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            Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography.

            Spontaneous pneumomediastinum (SPM) is described as free air or gas located within the mediastinum that is not associated with any noticeable cause such as chest trauma. SPM has been associated with many conditions and triggers, including bronchial asthma, diabetic ketoacidosis, forceful straining during exercise, inhalation of drugs, as well as other activities associated with the Valsalva maneuver. The Macklin effect appears on thoracic computed tomography (CT) as linear collections of air contiguous to the bronchovascular sheaths. With the recent availability of multidetector-row CT, the Macklin effect has been seen in the clinical setting more frequently than expected. The aim of this review article is to describe the CT imaging spectrum of the Macklin effect in patients with SPM, focusing on the common appearance of the Macklin effect, pneumorrhachis, and persistent SPM with pneumatocele.
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              Is Open Access

              Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty?

              Background In mechanically ventilated Acute Respiratory Distress Syndrome (ARDS) patients with novel coronavirus disease (COVID-19), we frequently recognised the development of pneumomediastinum and/or subcutaneous emphysema despite employing a protective mechanical ventilation strategy. The purpose of this study was to determine if the incidence of pneumomediastinum/subcutaneous emphysema in COVID-19 patients was higher than in ARDS patients without COVID-19 and if this difference could be attributed to barotrauma or to lung frailty. Methods We identified the cohort of patients with ARDS and COVID-19 (“CoV-ARDS”), and the cohort of patients with ARDS from other causes (“noCoV-ARDS”). Patients with CoV-ARDS were admitted to ICU during the COVID-19 pandemic and had microbiologically confirmed SARS-CoV-2 infection. NoCoV-ARDS was identified by an ARDS diagnosis in the 5 years before the COVID-19 pandemic period. Results Pneumomediastinum/subcutaneous emphysema occurred in 23 out of 169 (13.6%) patients with CoV-ARDS and in 3 out of 163 (1.9%) patients with noCoV-ARDS (p<0.001). Mortality was 56.5% in CoV-ARDS patients with pneumomediastinum/subcutaneous emphysema and 50% in patients without pneumomediastinum (p=0.46). CoV-ARDS patients had a high incidence of pneumomediastinum/subcutaneous emphysema despite the use of low tidal volume (5.9∓0.8 mL·kg−1 ideal body weight) and low airway pressure (plateau pressure 23∓4 cmH2O). Conclusions We observed a seven-fold increase in pneumomediastinum/subcutaneous emphysema in CoV-ARDS. An increased lung frailty in CoV-ARDS could explain this finding more than barotrauma, which, according to its etymology, refers to high transpulmonary pressure.

                Author and article information

                Respir Med
                Respir Med
                Respiratory Medicine
                Elsevier Ltd.
                20 April 2022
                20 April 2022
                [a ]Department of Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
                [b ]Department of Radiology, San Carlo Hospital, Potenza, Italy
                [c ]Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
                [d ]School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
                [e ]Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
                [f ]Department of Surgical-Medical Molecular Pathology and Critical Care Medicine, University of Pisa, Italy
                [g ]Department of Anesthesia e Critical Care Medicine, Cardiothoracic-Vascular Anesthesia and Intensive Care, University of Pisa, Italy
                Author notes
                []Corresponding author. Department of Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital Via Potito Petrone, 85100, Potenza, Italy.
                S0954-6111(22)00118-4 106853
                © 2022 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                Original Research

                acute respiratory distress syndrome,mechanical ventilation,tomography,x-ray computed,pneumothorax,pneumomediastinum,barotrauma,ards, acute respiratory distress syndrome,covid-19, coronavirus disease 2019,npv, negative predictive value,pmd, pneumomediastinum,pnx, pneumothorax,ppv, positive predictive value


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