Pneumomediastinum in patients with SARS-CoV-2 treated with non-invasive ventilation

SARS-CoV-2, causing the pandemic COVID-19, has rapidly spread, overwhelming healthcare systems. Non-invasive positive pressure ventilation (NIV) can be used as a bridging therapy to delay invasive mechanical ventilation or as a standalone therapy. Spontaneous pneumomediastinum is rare and self-limiting, but there is an increased incidence documented in COVID-19. Here we document two cases of pneumomediastinum-related prolonged NIV therapy in severe COVID-19. Patient 1, a 64-year-old man, who developed symptoms after NIV therapy was weaned and survived. Patient 2, an 82-year-old woman, failed to improve despite NIV therapy, on investigation was found to have a pneumomediastinum. After review, the patient was placed on best supportive care and died 3 days later. We highlight the importance of recognising less common causes of deterioration in severe COVID-19 treated with NIV. In addition, pneumomediastinum in these cases may not always lead to poor outcomes.