A radiological predictor for pneumomediastinum/pneumothorax in COVID-19 ARDS patients

• Published in: Journal of critical care Vol. 66; pp. 14 - 19
• Main Authors: Palumbo, Diego, Zangrillo, Alberto, Belletti, Alessandro, Guazzarotti, Giorgia, Calvi, Maria Rosa, Guzzo, Francesca, Pennella, Renato, Monti, Giacomo, Gritti, Chiara, Marmiere, Marilena, Rocchi, Margherita, Colombo, Sergio, Valsecchi, Davide, Scandroglio, Anna Mara, Dagna, Lorenzo, Rovere-Querini, Patrizia, Tresoldi, Moreno, Landoni, Giovanni, De Cobelli, Francesco, Faustini, Carolina, Maimeri, Nicolò, Lembo, Rosalba, Di Lucca, Giuseppe, Scotti, Raffaella, Lavorato, Maria Vittoria, Tomellieri, Alessandro, Campochiaro, Corrado, Darvizeh, Fatemeh, Calabrese, Francesca, Mapelli, Roberto, Pasculli, Nicola, Borghi, Giovanni, Cipriani, Antonella, Calabrò, Maria Grazia, Crivellari, Martina, Franco, Annalisa, Pieri, Marina, Fominskiy, Evgeny V., Franchini, Stefano, Dell'Acqua, Antonio, Marinosci, Alessandro, Vitali, Giordano, Compagnone, Nicola
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-12-2021; Elsevier Limited
• Subjects: Accuracy; Acute respiratory distress syndrome; Case-Control Studies; Coronaviruses; COVID-19; Critical care; Disease transmission; Emphysema; Humans; Lungs; Mechanical ventilation; Mediastinal Emphysema - diagnostic imaging; Medical imaging; Pneumomediastinum; Pneumothorax; Respiratory Distress Syndrome - diagnostic imaging; SARS-CoV-2; Severe acute respiratory syndrome coronavirus 2; Tomography, X-ray computed; Ventilators; Acute respiratory distress syndrome; COVID-19; Pneumothorax; NPV; LR; PMD; PPV; PNX; Tomography, X-ray computed; Mechanical ventilation; Pneumomediastinum; ARDS
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2021.07.022

To determine whether Macklin effect (a linear collection of air contiguous to the bronchovascular sheath) on baseline CT imaging is an accurate predictor for subsequent pneumomediastinum (PMD)/pneumothorax (PNX) development in invasively ventilated patients with COVID-19-related acute respiratory distress syndrome (ARDS).
This is an observational, case-control study. From a prospectively acquired database, all consecutive invasively ventilated COVID-19 ARDS patients who underwent at least one baseline chest CT scan during the study time period (February 25th, 2020–December 31st, 2020) were identified; those who had tracheal lesion or already had PMD/PNX at the time of the first available chest imaging were excluded.
37/173 (21.4%) patients enrolled had PMD/PNX; specifically, 20 (11.5%) had PMD, 10 (5.8%) PNX, 7 (4%) both. 33/37 patients with subsequent PMD/PNX had Macklin effect on baseline CT (89.2%, true positives) 8.5 days [range, 1–18] before the first actual radiological evidence of PMD/PNX. Conversely, 6/136 patients without PMD/PNX (4.4%, false positives) demonstrated Macklin effect (p < 0.001). Macklin effect yielded a sensitivity of 89.2% (95% confidence interval [CI]: 74.6–96.9), a specificity of 95.6% (95% CI: 90.6–98.4), a positive predictive value (PV) of 84.5% (95% CI: 71.3–92.3), a negative PV of 97.1% (95% CI: 74.6–96.9) and an accuracy of 94.2% (95% CI: 89.6–97.2) in predicting PMD/PNX (AUC:0.924).
Macklin effect accurately predicts, 8.5 days in advance, PMD/PNX development in COVID-19 ARDS patients.
•Macklin effect can be regarded as an early detector of lung frailty.•Macklin effect accurately predicts barotrauma in COVID-19 ARDS patients.•Median delay between Macklin effect first evidence and barotrauma onset was 8.5 days.•Patients with Macklin effect might benefit from ultraprotective ventilation strategy.