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Discussion

COVID-19: Pneumos

Are other hospitals seeing an increase lately in tension pneumothorax/ pbeumomediastinum? 

It seems like it's 1 in 4 ICU patients with these complications in the last 2-3 weeks. All ages and comorbidities (or lack of comorbidities) We're talking about steroids and barotrauma but we haven't changed dosing protocols or bipap/vent use since Summer. We didn't have these issues in Summer or fall. 

I hate this disease, it seems like there's always something new just as we start feeling like we can manage treatment. 

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    Back when our hospital sent a contingency to the Bronx early in the pandemic, the staff that came back did say that they saw a lot of pneumothorax in the COVID-19 patients.  Locally, we haven't seen a trend with the ones we have intubated and mechanically ventilated.  However, we never go above 6 cc/kg of Predicted Body Weight in our tidal volume settings and keep a close eye on plateau pressures.  What vent protocols do you use?

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    I think there are many things that have changed over the course of this illness. Last March we were seeing so many high fevers, >104, and the patients were nearly impossible to sedate. We had little old people that take nearly no medications maxed out on propofol, precedex and we were adding ketamine, versed, fentanyl and ativan at high doses to keep them sedated. Our patients were not having as many issues with clotting, and were did not have many incidents of pneumothorax or pneumomediastinum. 

    Recently we have had many more stroke patients come in positive for COVID. We had an awful death in a young woman that developed a retroperitoneal bleed, potentially from the high dose lovenox. We are seeing more PEs and we have had more people diagnosed with pneumomediastinum. We have not had any tension pneumothoraces. As far as I know we are also staying with the 6cc/kg tidal volumes. The patients that developed those complications have been intubated for greater than two weeks. 

    I totally agree that it has been so frustrating to feel like we might have something figured out when all of a sudden things change. We've been wondering whether the strain is different for a while. 

     

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