Correlation between continuous Positive end-expiratory pressure (PEEP) values and occurrence of Pneumothorax and Pneumomediastinum in SARS-CoV2 patients during non-invasive ventilation with Helmet Pneumothorax and Pneumomediastinum in NIV with Helmet CPAP

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Antonio Gidaro
Federica Samartin
Anna Maria Brambilla
Chiara Cogliati
Stella Ingrassia
Francesco Banfi
Viola Cupiraggi
Cecilia Bonino
Marco Schiuma
Andrea Giacomelli
Stefano Rusconi
Jaqueline Currà
Antonio Luca Brucato
Emanuele Salvi


Pneumothorax, Pneumomediastinum, CPAP, PEEP, COVID-19


Background: Acute Hypoxemic Respiratory Failure (AHRF) is a common complication of Covid-19 related pneumonia, for which non-invasive ventilation (NIV) with Helmet Continuous Positive Airway Pressure (CPAP) is widely used. The frequency of pneumothorax in COVID-19 was reported in 0.95% of hospitalized patients in 6% of mechanically ventilated patients, and in 1% of a post-mortem case series. Objectives: Aim of our retrospective study was to investigate the incidence of pneumothorax and pneumomediastinum (PNX/PNM) in COVID-19 pneumonia patients treated with Helmet CPAP. Moreover, we examined the correlation between PNX/PNM and Positive end-expiratory pressure (PEEP) values. Methods: We collected data from patients admitted to “Luigi Sacco” University Hospital of Milan from 2 February to 5 May 2020 with COVID-19 pneumonia requiring CPAP. Patients, who need endotracheal intubation (ETI) for any reason except those who needed ETI after PNX/PNM, were excluded.  Population was divided in two groups according to PEEP level used under CPAP (≤10 cmH2O and >10 cmH20). Results: One hundred fifty-four patients were enrolled. In the overall population, 42 patients (27%) were treated with High-PEEP (>10 cmH2O), and 112 with Low-PEEP (≤10 cmH2O). During hospitalization 3 PNX and 2 PNM occurred (3.2%). Out of these five patients, 2 needed invasive ventilation after PNX and died. All the PNX/PNM occurred in the High-PEEP group (5/37 vs 0/112, p<0,001). Conclusion: The incidence of PNX appears to be lower in COVID-19 than SARS and MERS. Considering the association of PNX/PNM with high PEEP we suggest using the lower PEEP as possible to prevent these complications.


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