Case 2
A 71-year-old man with a past medical history of osteoarthritis and
hypertension bring managed with amlodipine presented to the hospital
with signs of COVID-19 pneumonia and moderate ARDS. He was initially
managed with a non-rebreathing oxygen mask, self-proning, and
noninvasive ventilation. He was managed with antibiotics, antivirals,
steroids, and as he showed signs of cytokine storm, IL-6 antagonist
Tocilizumab was given. Later, he also received convalescent plasma from
recovered COVID-19 donors. The management was done according to the
hospital’s COVID-19 management guidelines. During his course in the
hospital, he developed hospital-acquired secondary pneumonia fromEnterobacter cloacae , Candida , and Acinetobacter
baumanni . Bronchoalveolar lavage grew Stenotrophomonas
maltophilia . He was intubated and ventilated on day 32 in the hospital
due to worsening of ARDS, sepsis, multiorgan dysfunction syndrome
(MODS).
Ventilatory requirements remained high during this period and on day 37,
his chest radiographs showed pneumomediastinum, subcutaneous emphysema
with no pneumothorax. His ventilator settings on that day were CMV mode
with FiO2 40%, positive end-expiratory pressure
(PEEP) of 8mmHg, tidal volume 370 ml, and respiratory rate of 26/minute.
Computerized topography (CT) scan showed extensive surgical emphysema in
the neck and anterior-lateral aspect of the chest wall, which was more
prominent in the right side. Extensive tension pneumo-mediastinum was
noted extending from the superior mediastinum, anterior mediastinum,
posterior mediastinum and extending even to the retroperitoneum space
surrounding the pancreas and left kidney. No evidence of
pneumoperitoneum was found. Bilateral thin rim of pneumothorax was noted
slightly more on the left side. No evidence of lung collapse was seen in
the CT scan.
Conservative management was adopted for his pneumo-mediastinum by
reducing the ventilator pressures and close observation. The condition
resolved over time. He was tracheostomized on day 12 due to a prolonged
ventilatory course. He developed recurrent sepsis during his stay in the
ICU; however, due to timely management, his condition improved over
time. The patient was discharged from the ICU on day 29.