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

  1. Hariprasad Kalpakam
  2. Sameer Bansal
  3. Nithya Suresh
  4. Samson Kade
  5. Anmol Thorbole
  6. Ravindra M Mehta

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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.

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    SciScore for 10.1101/2021.02.12.21251479: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has several limitations. The data in our study is a reflection of a particular strategy, namely initial NIV resorting to iMV as a last resort and reflects the incidence of barotrauma and outcomes with such an approach. In addition to being an expert recommendation, this also was a pragmatic approach considering imminent ventilator and staffing shortages, as iMV and proning requires more intensive resources. Another limitation inherent in this approach is the varying inflation pressures and fluctuating PEEP with NIV, challenges in implementing desired tidal volume and difficulties in precise monitoring. NIV also comes with potential abrupt transitions from ventilation to supportive oxygen and vice-versa as patients are given breaks for compliance, eating and other activities, all of which could be possible risk factors for barotrauma. In addition, as it was not possible to do CT scans in these sick C-ARDS patients, we were unable to define pre-existing or newly developed pulmonary lesions such as emphysema, cysts, underlying fibrotic lung disease, onset of new COVID-related fibrosis and small cavities. The mean Pplat. in our study is the upper limit of normal and reflects the stiff lungs in severe C-ARDS, with likely fibrosis in the patients who were treated beyond 2-3 weeks.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  2. Version published to 10.1101/2021.02.12.21251479v1 on medRxiv