Severe COVID-19 pneumonia and barotrauma: From the frying pan into the fire

Abstract Aim COVID-19 pneumonia with ARDS (C-ARDS) has a high mortality. Preliminary reports indicate a higher incidence of barotrauma in patients with C-ARDS[1] both on invasive mechanical ventilation (iMV) and non-invasive ventilation (NIV) This study examines the incidence and risk factors for barotrauma and change in outcomes after barotrauma in patients with severe C-ARDS on positive pressure respiratory support (PPRS). Methods and materials This is a retrospective study of C-ARDS associated barotrauma over 5 months in patients on PPRS in a tertiary COVID care center. The type of barotrauma, intervention, related factors, such as type of respiratory support (iMV vs NIV), airway pressure prior to the occurrence of barotrauma, and post-barotrauma outcomes were analyzed. Results A total of 38/410 (9.3%) C-ARDS patients on PPRS [mean age 57.82 ± 13.3 years, 32 males (84.2%)] developed barotrauma. Of these, 20 patients (52.6%) were on NIV and 18 (47.4%) patients were iMV on standard recommended settings. The median P/F ratio of patients on MV at the time of barotrauma was 116.4 (IQR 72.4, 193.25). The details of barotrauma were as follows: 24 patients had pneumothorax (PTX), 2 had pneumo-mediastinum and 12 had subcutaneous emphysema. Overall, 24/38 (63.2%) patients, including 15/18 (83.3%) on MV succumbed to their illness. The barotrauma happened a median of 6.5 days (IQR 4.75,13) after admission and 15 days (IQR 10.25,18.0) from symptom onset. The median duration from barotrauma to death was 7 days (IQR 2.25, 8.0) and barotrauma to discharge (for survivors) was 12.5 days (IQR 8.0, 21.25). All patients received steroids and 11/38 (28.9%) received additional immunosuppression with tocilizumab. Conclusion A high incidence of barotrauma was seen in this large series of severe C-ARDS patients on PPRS. Barotrauma led to further deterioration in the clinical status leading to a fatal outcome in the majority of the MV patients, despite prompt treatment.