key: cord-0708980-mirweubh authors: Fu, Bao; Hu, Jie; Chen, Tao; Fu, Xiaoyun title: Tracheal Membrane Rupture as the Cause of Pneumomediastinum in a Patient with COVID-19 date: 2022-03-18 journal: Korean J Radiol DOI: 10.3348/kjr.2021.0947 sha: 72d787ba34b5377a6f9b090975abf7b45b8e273e doc_id: 708980 cord_uid: mirweubh nan Recently, pneumomediastinum has been reported in patients with coronavirus disease 2019 (COVID-19) including cases published in the Korean Journal of Radiology [1] [2] [3] . Endotracheal intubation is commonly performed to treat COVID-19; tracheal membrane injury, a rare and potentially life-threatening complication associated with this procedure, can cause pneumomediastinum. The most common symptoms of tracheal injury are dyspnea, subcutaneous emphysema, and mediastinal emphysema. Diagnosis requires a high suspicion index and is thus often delayed; indeed, intubation, iatrogenic tracheal injuries were confirmed in nearly 15% of emergency intubations according to autopsy [4] . Herein, we report a case of tracheal membrane rupture after tracheal intubation and invasive mechanical ventilation in a patient with COVID-19. An 80-year-old female was diagnosed with COVID-19 and admitted to the hospital. The physical examination findings were as follows: temperature, 36.7°C; heart rate, 86 beats/min; respiratory rate, 20 beats/min, oxygen saturation, 97% (in room air); and blood pressure, 116/95 mm Hg. Chest computed tomography (CT) on admission revealed exudative lesions in both the upper and lower lobes of the left lung (Fig. 1A) . As her condition worsened, she was transferred to the intensive care unit (ICU). She received awake prone position therapy and noninvasive mechanical ventilation. Two days after ICU admission, the patient underwent visual laryngoscope-guided tracheal intubation. On the second day after tracheal intubation, she underwent a re-examination of chest CT, and the results showed extensive subcutaneous emphysema and mediastinal emphysema (Fig. 1B) . Further, chest CT showed rupture of the tracheal membrane (Fig. 1C) . She developed severe acute respiratory distress syndrome and subsequently received veno-venous extracorporeal membrane oxygenation (V-V ECMO) as treatment. After 5 days of ECMO treatment, bedside X-ray examination showed that the emphysema had been absorbed (Fig. 1D ). At present, the patient's condition remains stable. Tracheal membrane rupture is typically caused by mechanical injuries. The incidence of tracheobronchial injury in patients with chest and neck trauma, including death, is between 0.5% and 2.0% [5] . Iatrogenic causes of tracheal injury include percutaneous dilatation, tracheostomy, tracheal intubation, and hard bronchoscopy [6] . The patient was intubated a day before the development of a suspected tracheal injury. The intubation process was smooth and gentle; therefore, the possibility of tracheal membrane injury induced by intubation procedure was relatively low. A previous study reported the first case of tracheal stenosis due to viral tracheitis associated with COVID-19 [7] . A recent study also reported two cases of COVID-19related laryngotracheitis [8] . Therefore, we speculate that tracheal membrane injury in this patient may be related to tracheal inflammation caused by COVID-19 rather than mechanical injury. If tracheal injury can be detected and treated in time, the outcome is generally good. Chest X-rays are the initial method to evaluate trauma patients and may show signs of tracheal injury, including symptoms of subcutaneous emphysema, mediastinal emphysema, or "fallen lung" [9] . CT imaging has been shown to have an accuracy rate of 94%-100% in diagnosing tracheal injuries, and bronchoscopy is the gold standard for detecting tracheal damage [9] . Once tracheal injury is determined, the first problem https://doi.org/10.3348/kjr.2021.0947 kjronline.org that needs to be solved is how to deal with the patient's airway. Different oxygenation and ventilation methods can be used according to the location of the injury. A common method is to advance the endotracheal tube past the injury, allowing oxygenation and ventilation, while minimizing the risk of positive pressure. Owing to severe hypoxemia, this patient received V-V ECMO, which guarantees oxygenation. In this case, temporary use of ECMO allowed the trachea to heal while avoiding the sequelae of hypoxia. When the trachea is severely ruptured, a one-stage surgical repair with V-V ECMO support can be considered. The authors have no potential conflicts of interest to disclose. Mediastinal emphysema, giant bulla, and pneumothorax developed during the course of COVID-19 pneumonia Spontaneous pneumomediastinum: a probable unusual complication of coronavirus disease 2019 (COVID-19) pneumonia Spontaneous pneumomediastinum in a patient with coronavirus disease 2019 pneumonia and the possible underlying mechanism Outcome of tracheobronchial injuries: a longterm perspective Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment Tracheal injury Tracheal stenosis following mild-to-moderate COVID-19 infection without history of tracheal intubation: a case report Appearance and management of COVID-19 laryngo-tracheitis: two case reports Repair of tracheobronchial injuries Thanks the patient and her family.