Pneumothorax and pneumomediastinum in COVID-19 acute respiratory distress syndrome


  • Amos Lal | Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States.
  • Ajay Kumar Mishra Department of Medicine, Saint Vincent Hospital, Worcester, MA, United States.
  • Jamal Akhtar Department of Sleep Medicine, Montefiore Medical Center, Bronx, New York, NY, United States.
  • Christoph Nabzdyk Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN, United States.


COVID-19 has involved numerous countries across the globe and the disease burden, susceptible age group; mortality rate has been variable depending on the demographical profile, economic status, and health care infrastructure. In the current clinical environment, COVID-19 is one of the most important clinical differential diagnoses in patients presenting with respiratory symptoms. The optimal mechanical ventilation strategy for these patients has been a constant topic of discussion and very importantly so, since a great majority of these patients require invasive mechanical ventilation and often for an extended period of time. In this report we highlight our experience with a COVID-19 patient who most likely suffered barotrauma either as a result of traumatic endotracheal intubation or primarily due to COVID-19 itself. We also aim to highlight the current literature available to suggest the management strategy for these patients for a favorable outcome. The cases described are diverse in terms of age variance and other comorbidities. According to the literature, certain patients, with COVID-19 disease and spontaneous pneumothorax were noted to be managed conservatively and oxygen supplementation with nasal cannula sufficed. Decision regarding need and escalation to invasive mechanical ventilation should be taken early in the disease to avoid complications such as patient self-inflicted lung injury (P-SILI) and barotrauma sequelae such as pneumothorax and pneumomediastinum Recent systematic review further supports the fact that the use of non-invasive ventilation (NIV) in certain patients with COVID-19 pneumonia may give a false sense of security and clinical stabilization but has no overall benefit to avoid intubation. While invasive mechanical ventilation may be associated with higher rates of barotrauma, this should not mean that intubation and invasive mechanical ventilation should be delayed. This becomes an important consideration when non-intensivists or personnel with less experience provide care for this vulnerable patient population who may rely too heavily on NIV to avoid intubation and mechanical ventilation.



PlumX Metrics


Download data is not yet available.


Sahu KK, Mishra AK, Lal A. Comprehensive update on current outbreak of novel coronavirus infection (2019-nCoV). Ann Transl Med 2020;8:393. DOI:

Sahu KK, Mishra AK, Lal A. COVID-2019: update on epidemiology, disease spread and management. Monaldi Arch Chest Dis 2020;90:1292. DOI:

Sahu KK, Mishra AK, Lal A. Novel coronavirus (2019-nCoV): Update on 3rd coronavirus outbreak of 21st century. QJM 2020;113:384-6. DOI:

Wu Z, McGoogan JM. Characteristics of and Important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42. DOI:

Soy M, Keser G, Atagündüz P, et al. Cytokine storm in COVID-19: pathogenesis and overview of anti-inflammatory agents used in treatment. Clin Rheumatol 2020:39:2085-94. DOI:

Lal A, Mishra AK, Sahu KK. CT chest findings in coronavirus disease-19 (COVID-19). J Formos Med Assoc 2020;119:100-1. DOI:

Martinelli AW, Ingle T, Newman J, et al. COVID-19 and pneumothorax: A multicentre retrospective case series. Eur Respir J 2020;56:2002697. DOI:

Lal A, Mishra AK, John K, et al. Corticosteroids and rehabilitation in COVID-19 survivors. J Formos Med Assoc Online ahead of print 2020;S0929-6646(20)30605-7. DOI:

Lal A, Mishra AK, Sahu KK. Prevention of early ventilator-associated pneumonia. N Engl J Medic 2020;382:1671-2. DOI:

Liu K, Zeng Y, Xie P, et al. COVID-19 with cystic features on computed tomography: a case report. Medicine (Baltimore) 2020;99:e20175. DOI:

Bor C, Demirağ K, Uyar M, et al. Recurrent spontaneous pneumothorax during the recovery phase of ARDS due to H1N1 infection. Balkan Med J 2013;30:123-5. DOI:

Gattinoni L, Caironi P, Pelosi P, et al. What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 2001;164:1701-11. DOI:

Joynt GM, Antonio GE, Lam P, et al. Late-stage adult respiratory distress syndrome caused by severe acute respiratory syndrome: abnormal findings at thin-section CT. Radiology 2004;230:339-46. DOI:

Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395:507-13. DOI:

Sun R, Liu H, Wang X. Mediastinal emphysema, giant bulla, and pneumothorax developed during the course of COVID-19 pneumonia. Korean J Radiol 2020;21:541-4. DOI:

Cheng ZJ, Shan J. 2019 Novel coronavirus: where we are and what we know. Infection 2020;48:155-63. DOI:

Salehi S, Abedi A, Balakrishnan S, et al. Coronavirus Disease 2019 (COVID-19): A systematic review of imaging findings in 919 patients. AJR Am J Roentgenol 2020;215:87-93. DOI:

Gattinoni L, Coppola S, Cressoni M, et al. COVID-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med 2020;201:1299-300. DOI:

Gattinoni L, Chiumello D, Caironi P, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Med 2020;46:1099-102. DOI:

Schünemann HJ, Khabsa J, Solo K, et al. Ventilation techniques and risk for transmission of coronavirus disease, including COVID-19: A living systematic review of multiple streams of evidence. Ann Intern Med 2020;173:204-16. DOI:

Arulkumaran N, Brealey D, Howell D, et al. Use of non-invasive ventilation for patients with COVID-19: a cause for concern? Lancet Respir Med 2020;8:e45. DOI:

Patel BK, Kress JP, Hall JB. Alternatives to Invasive ventilation in the COVID-19 pandemic. JAMA 2020;324:43-4. DOI:

Kangelaris KN, Ware LB, Wang CY, et al. Timing of intubation and clinical outcomes in adults with acute respiratory distress syndrome. Critical Care Med 2016;44:120-9. DOI:

Kwon AH, Slocum AH Jr., Varelmann D, et al. Rapidly scalable mechanical ventilator for the COVID-19 pandemic. Intensive Care Med 2020;46:1642-4. DOI:

Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med 2016;195:438-42. DOI:

Duan J, Han X, Bai L, et al. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med 2017;43:192-9. DOI:

Roca O, Messika J, Caralt B, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: The utility of the ROX index. J Crit Care 2016;35:200-5. DOI:

López Vega JM, Parra Gordo ML, Diez Tascón A, et al. Pneumomediastinum and spontaneous pneumothorax as an extrapulmonary complication of COVID-19 disease. Emerg Radiol 2020;27:727-30. DOI:

McGuinness G, Zhan C, Rosenberg N, et al. High incidence of barotrauma in patients with COVID-19 Infection on invasive mechanical ventilation. Radiology 2020;297:e252-62. DOI:

de Durante G, del Turco M, Rustichini L, et al. ARDSNet lower tidal volume ventilatory strategy may generate intrinsic positive end-expiratory pressure in patients with acute respiratory distress syndrome. Am J Respir Critl Care Med 2002;165:1271-4. DOI:

Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81. DOI:

Prokakis C, Koletsis EN, Dedeilias P, et al. Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment. J Cardiothorac Surg 2014;9:117. DOI:

Lal A, Akhtar J, Jindal V, et al. Rare cause of respiratory failure: A twist in the tale. Ann Am Thorac Soc 2018;15:880-3. DOI:

Lal A, Akhtar J, Khan MS, et al. Primary endobronchial amyloidosis: A rare case of endobronchial tumor. Respir Med Case Rep 2018;23:163-6. DOI:

Lal A, Akhtar J, Pinto S, et al. Recurrent pulmonary embolism and hypersensitivity pneumonitis secondary to aspergillus, in a compost plant worker: Case report and review of literature. Lung 2018;196:553-60. DOI:

Lal A, Davis MJ, Akhtar J, et al. Serious cover-up: Hodgkin's lymphoma masked by organizing pneumonia. Am J Med 2018;131:1174-7. DOI:

Lal A, Mishra AK, Sahu KK, et al. The return of Koch's: Ineffective treatment or re-infection. Enferm Infecc Microbiol Clin 2020;38:144-5. DOI:

Lal A, Nabzdyk C, Ramakrishna H, et al. Consider heightened awareness of propofol infusion syndrome after extracorporeal membrane oxygenation (ECMO) decannulation. J Cardiothorac Vasc Anesth 2020;34:2174-7. DOI:

Lal A, Mishra AK, Sahu KK, et al. Spontaneous pneumomediastinum: Rare complication of tracheomalacia. Arch Bronconeumol 2020;56:185-6. DOI:

Seelhammer TG, Plack D, Lal A, Nabzdyk CGS. COVID-19 and ECMO: An unhappy marriage of endothelial dysfunction and hemostatic derangements. J Cardiothorac Vasc Anesth 2020;34:3193-6. DOI:

Bartlett RH, Ogino MT, Brodie D, et al. Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure. ASAIO J 2020;66:472-4. DOI:

Lal A, Pena ED, Sarcilla DJ, et al. Ideal length of oral endotracheal tube for critically ill intubated patients in an Asian population: Comparison to current western standards. Cureus 2018;10:e3590. DOI:

Lal A, Mishra AK, Sahu KK. Vitamin E acetate and e-cigarette or vaping product-associated lung injury (EVALI): An update. Am J Med 2020;133:e204. DOI:

Aydın S, Öz G, Dumanlı A, et al. A case of spontaneous pneumothorax in Covid-19 pneumonia. J Surg Res 2020;3:096-101. DOI:

Flower L, Carter J-PL, Rosales Lopez J, et al. Tension pneumothorax in a patient with COVID-19. BMJ Case Rep 2020;13:e235861. DOI:

Hollingshead C, Hanrahan J. Spontaneous pneumothorax following COVID-19 pneumonia. IDCases 2020;21:e00868. DOI:

Spiro JE, Sisovic S, Ockert B, et al. Secondary tension pneumothorax in a COVID-19 pneumonia patient: a case report. Infection 2020;48:941-4. DOI:

Romano N, Fischetti A, Melani EF. Pneumomediastinum related to Covid-19 pneumonia. Am J Med Sci 2020;360:e19-e20. DOI:

Alhakeem A, Khan MM, Al Soub H, et al. Case Report: COVID-19–associated bilateral spontaneous pneumothorax - A literature review. Am J Trop Med Hyg 2020;103:1162-5. DOI:

Mallick T, Dinesh A, Engdahl R, Sabado M. COVID-19 complicated by spontaneous pneumothorax. Cureus 2020;12:e9104. DOI:

Rachidi SA, Motiaa Y. Spontaneous pneumothorax associated with COVID-19. Glob J Medical Clin Case Rep 2020;7:043. DOI:

Ucpinar BA, Sahin C, Yanc U. Spontaneous pneumothorax and subcutaneous emphysema in COVID-19 patient: Case report. J Infect Public Health 2020;13:887-9. DOI:


COVID-19 - Collection of articles on the Coronavirus outbreak
COVID-19, pneumothorax, pneumomediastinum, critical care, intensive care
  • Abstract views: 1090

  • PDF: 443
  • VIDEO: 22
How to Cite
Lal, Amos, Ajay Kumar Mishra, Jamal Akhtar, and Christoph Nabzdyk. 2021. “Pneumothorax and Pneumomediastinum in COVID-19 Acute Respiratory Distress Syndrome”. Monaldi Archives for Chest Disease 91 (2).

Most read articles by the same author(s)