Mediastinum Intubation and Decompression Technique for Management of Tension Pneumomediastinum

Tension pneumomediastinum is one of the life-threatening complications of COVID-19 (coronavirus disease 2019). The patient in this video is a sixty-six-year-old man with complaints of cough and high-grade fever for a week prior. He had systemic hypertension and type II diabetes mellitus. He tested positive for COVID-19 on a rapid PCR test. His high resolution computed tomography (HRCT) severity score was 14/25. He was diagnosed with viral pneumonitis and acute respiratory failure.

The patient then suddenly started to develop large subcutaneous emphysema involving the face, neck, chest, and abdomen, extending all the way to both knee joints. He also developed sudden hypotension, requiring ionotropic support. As the patient's oxygen saturation (SPO2) worsened on noninvasive ventilation, he was intubated and given mechanical ventilation support with volume control mode, a fraction of inspired oxygen (FIO2) of 100 percent, and positive end expiratory pressure (PEEP) of 5 cm H2O. His SPO2 was 82 percent. 

HRCT revealed extensive pneumomediastinum with a thick layer of air above the pericardium. Tension pneumomediastinum was suspected. The patient underwent emergency mediastinum intubation and decompression using the mediastinum intubation and decompression (MID) technique. Immediately after the procedure, the patient’s blood pressure and saturation improved. Subcutaneous emphysema reduced significantly within 24 hours. Chest X-rays and HRCT were done to document the resolution of air in the mediastinum. The lung compliance pressures improved and allowed for effective tidal volume delivery.

References

1. Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. Journal of the Intensive Care Society. 2017;18(1):52-56. doi:10.1177/1751143716662665

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