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      Neumomediastino espontáneo en pacientes COVID-19. Serie de casos Translated title: Spontaneous pneumomediastinum in COVID-19 patients. Case series

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          Abstract

          Resumen El neumomediastino espontáneo es la presencia de aire libre en el mediastino sin el antecedente de alguna causa como trauma de tórax. Es una condición benigna autolimitada que se trata en forma conservadora. El diagnóstico clínico se basa en dos síntomas: dolor torácico y disnea; y en un signo en particular: enfisema subcutáneo. Ha sido reportado en pacientes con influenza A (H1N1) y síndrome respiratorio agudo grave; sin embargo, ha sido raramente observado en pacientes con COVID-19. En este trabajo describimos seis pacientes del sexo masculino con COVID-19, con edades entre 27 y 82 años, que presentaron neumomediastino espontáneo y enfisema subcutáneo; ambos se reabsorbieron totalmente con manejo conservador.

          Translated abstract

          Abstract Spontaneous pneumomediastinum is defined as the presence of free air within the mediastinum without an apparent cause such as chest trauma. It is a benign, self-limiting condition that is conservatively treated. Clinical diagnosis is based on two symptoms: chest pain and dyspnea; and on a particular sign: subcutaneous emphysema. It has been reported in patients with influenza A (H1N1) and severe acute respiratory syndrome; however, it has been rarely observed in COVID-19 patients. In this work, we describe six male patients with COVID-19, aged between 27 and 82 years, who presented with spontaneous pneumomediastinum and subcutaneous emphysema; both conditions were completely resorbed with conservative management.

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          Pneumomediastinum.

          Pneumomediastinum is a condition in which air is present in the mediastinum. This condition can result from physical trauma or other situations that lead to air escaping from the lungs, airways or bowel into the chest cavity. Pneumomediastinum is a rare situation and occurs when air leaks into the mediastinum. The diagnosis can be confirmed via chest X-ray or CT scanning of the thorax. The main symptom is usually severe central chest pain. Other symptoms include laboured breathing, voice distortion (as with helium) and subcutaneous emphysema, specifically affecting the face, neck, and chest. Pneumomediastinum can also be characterized by the shortness of breath that is typical of a respiratory system problem. It is often recognized on auscultation by a "crunching" sound timed with the cardiac cycle (Hamman's crunch). Pnemomediastinum may also present with symptoms mimicking cardiac tamponade as a result of the increased intrapulmonary pressure on venous flow to the heart. The tissues in the mediastinum will slowly resorb the air in the cavity so most pneumomediastinums are treated conservatively.
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            Spontaneous pneumomediastinum in patients with severe acute respiratory syndrome.

            Spontaneous pneumomediastinum (SP) unrelated to assisted ventilation is a newly recognised complication of severe acute respiratory syndrome (SARS). The objective of the present study was to examine the incidence, risk factors and the outcomes of SP in a cohort of SARS victims from a community outbreak. Data were retrieved from a prospectively collected database of virologically confirmed SARS patients. One hundred and twelve cases were analysable, with 13 patients developing SP (11.6%) at a mean +/- SD of 19.6 +/- 4.6 days from symptom onset. Peak lactate dehydrogenase level was associated with the development of SP. SP was associated with increased intubation and a trend towards death. Drainage was required in five cases. For patients who survived, the SP and/or the associated pneumothoraces took a median of 28 days (interquartile range: 15-45 days) to resolve completely. In conclusion, spontaneous pneumomediastinum appeared to be a frequent complication of severe acute respiratory syndrome. Further research is needed to investigate its pathogenesis.
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              Relationship between ventilatory settings and barotrauma in the acute respiratory distress syndrome.

              High pressures or volumes may increase the risk of barotrauma in the acute respiratory distress syndrome (ARDS). The first part of the study analyzed data from a prospective trial of two ventilation strategies in 116 patients with ARDS retrospectively, and ventilatory pressures and volumes were compared in patients with or without pneumothorax. The second part consisted of a literature analysis of prospective trials (14 clinical studies, 2270 patients) describing incidence and risk factors for barotrauma in ARDS patients, and mean values of ventilatory parameters were plotted against incidence of barotrauma. In our clinical trial comparing two tidal volumes, 15 patients (12.3%) developed pneumothorax. There was no significant difference in any pressure or volume between these patients and the rest of the population, including end-inspiratory plateau pressure (P(plat)), driving pressure (P(plat)-PEEP), respiratory rate and compliance. Multiple trauma was more frequent among patients with pneumothorax (27%) than in those without (7%). Duration of mechanical ventilation tended to be longer with pneumothorax. In the literature review, the incidence of barotrauma varied between 0% and 49%, and correlated strongly with P(plat), with a high incidence above 35 cmH(2)O, and with compliance, with a high incidence below 30 ml/cmH(2)O. Clinical studies maintaining P(plat) lower than 35 cmH(2)O found no apparent relationship between ventilatory parameters and pneumothorax. Analysis of the literature suggests a correlation when patients receive mechanical ventilation with P(plat) levels exceeding 35 cmH(2)O.
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                Author and article information

                Journal
                gmm
                Gaceta médica de México
                Gac. Méd. Méx
                Academia Nacional de Medicina de México A.C. (Ciudad de México, Ciudad de México, Mexico )
                0016-3813
                2696-1288
                February 2021
                : 157
                : 1
                : 116-120
                Affiliations
                [2] Ciudad de México orgnameInstituto Nacional de Enfermedades Respiratorias orgdiv1Departamento de Urgencias México
                [1] Ciudad de México orgnameInstituto Nacional de Enfermedades Respiratorias orgdiv1Servicio de Cirugía Cardiotorácica México
                Article
                S0016-38132021000100116 S0016-3813(21)15700100116
                10.24875/gmm.20000839
                ac88961c-a449-4022-a40d-1e0f22a7d5c6

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

                History
                : 10 December 2020
                : 20 November 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 9, Pages: 5
                Product

                SciELO Mexico

                Categories
                Comunicación breve

                Spontaneous pneumomediastinum,Neumomediastino espontáneo,Enfisema subcutáneo,Efecto Macklin,COVID-19,Subcutaneous emphysema,Macklin effect

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