Surgical treatment of tension pneumomediastinum in patients with covid-19 at the field hospital: a case series

BACKGROUND: Tension pneumomediastinum is one of the most serious complications in COVID-19 patients with respiratory distress requiring invasive mechanical ventilation. This complication can lead to rapid hemodynamic instability and death if it is not recognized in a timely manner and intervenes promptly. CASE PRESENTATION: We reported 7 COVID-19 patients with tension pneumomediastinum at a field hospital. All patients were critically ill with ARDS. These 7 patients, including 3 females and 4 males in this series, were aged between 39 and 70 years. Tension pneumomediastinum occurred on the first day of mechanical ventilation in 3 patients and later in the course of hospital stay, even 10 days after being intubated and ventilated. The tension pneumomediastinum caused hemodynamic instability and worsened respiratory mechanics with imminent cardiopulmonary collapse. In this series, we used two surgical techniques: (i) mediastinal decompression by suprasternal drainage with or without simultaneous pleural drainage in the first two cases and (ii) mediastinal drainage via suprasternal and subxiphoid incisions in 5 patients. The surgical procedures were feasible and reversed the pending cardiopulmonary collapse. Four patients had a favorable postprocedural period and were discharged from the intensive care center. Both patients undergoing suprasternal drainage died of failed/recurrent tension pneumomediastinum and nosocomial infection. Only one in five patients who underwent mediastinal drainage via suprasternal and subxiphoid incisions died of septic shock secondary to ventilator-associated pneumonia. CONCLUSION: Tension pneumomediastinum was a life-threatening complication in critically ill COVID-19 patients requiring mechanical ventilation. Surgical mediastinal decompression was the salvage procedure. The surgical technique of mediastinal drainage via suprasternal and subxiphoid incisions proved an advantage in tension relief, hemodynamic improvement and mortality reduction.