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http://ijmsnr.com/
DOI
10.55349/ijmsnr.2022222528
Air Leak Syndrome and Coronavirus Disease 2019 (Covid-19)
Pneumonia – A Case Series
Eugene Alex Joshua1* , Karthikeyan Sellamuthu1, Rajesh Jeyaprakash1, Anand Khushvinder Singh2,
Kanagalakshmi Rameshkumar3, Chandrakala Sankarapandian4
1Associate Consultant, 2Senior Consultant, 3Junior Consultant, Department of critical care Medicine and Toxicology, Meenakshi
Mission Hospital and Research Center, Madurai, Tamil Nadu, India. 4Assistant Professor, Medical Surgical Nursing Department,
Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia.
1Senior Resident, Department of Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India. 2Assistant Professor,
Department of Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India. 3Professor and HOD, Department of
Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India.
Background: The COVID 19 pandemic caused by Severe Acute Respiratory Syndrome Corona Virus – 2 has affected millions around the
globe. It presents with a multisystem involvement, predominantly affecting the respiratory system. Spontaneous Air leak syndrome which
includes subcutaneous emphysema, pneumomediastinum and pneumothorax has been reported as one of the complications of COVID-19
pneumonia.
Method: This is a series of 10 cases, which presented with one or more manifestations of air leak syndrome among patients with covid 19
positive admitted in intensive care unit of Meenakshi Mission Hospital and Research Center, Madurai, India.
Results: Out of the 365 cases analyzed, 10 cases developed either subcutaneous emphysema, pneumomediastinum or pneumothorax. The
incidence rate was 2.73% per 1000 population. None of the 10 patients was on invasive mechanical ventilation before developing air leak
syndrome. No one had undergone an invasive procedure like central venous cannulation, intubation or bronchoscopy prior to the onset of
air leak. Age group of the sample was 38 to 68 years. All the cases had elevated D-Dimer values.
Conclusion: present case series shows that air leak syndrome can develop in COVID-19 patients receiving oxygenation through Nin-Invasive
Ventilation (NIV) and High flow Nasal Cannula (HFNC).
Recommendation: Patients with covid 19 who develop subcutaneous emphysema and pneumomediastinum should be carefully monitored
for signs of pneumothorax which can be life threatening in a sick patient with borderline oxygenation.
Keywords: COVID-19 pneumonia, subcutaneous emphysema, pneumomediastinum, pneumothorax
Introduction
COVID-19 pneumonia causes a spectrum of signs and syndromes ranging from mild upper respiratory tract symptoms to full blown Acute
Respiratory Distress Syndrome (ARDS). [1] The severe form of COVID pneumonia causes diffuse alveolar damage, organizing and fibrinous
consolidation. Similar to other causes of ARDS, COVID-19 also causes micro and macro thrombi in the pulmonary vasculature leading to
impaired oxygenation and further lung damage. Air leak syndrome is a clinical condition caused by leakage of air from the alveoli into
spaces which are normally devoid of air. This includes subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumopericardium
and pneumoperitoneum. One or more forms of this air leak syndrome has been reported to occur during the course of COVID-19 illness. [2]
The exact incidence of this syndrome, pathophysiology and its clinical significance is not well established. We present a series of 10 cases
of alveolar air leak syndrome in COVID-19 pneumonia patients over a 6-months period in our intensive care unit.
Materials and Methods
Meenakshi Mission Hospital and Research Center, Madurai, Tamil Nadu, intensive care unit cared for 365 critically ill COVID-19 pneumonia
patients between January and June 2021. All patients tested positive for COVID-19 on had a Real –Time Reverse Transcription Polymerase
Chain Reaction (RT- PCR). Each patient had a High-Resolution Computed Tomography (CT) scan at admission and orderly chest X-Rays.
How to cite this article: Joshua EA, Sellamuthu K, Jeyaprakash R, Singh AK, Rameshkumar K, Sankarapandian C. Air Leak Syndrome
and Coronavirus Disease 2019 (Covid-19) Pneumonia – A Case Series. Int J Sci and Med Res 2022;2(2):25-28
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-Non-Commercial-ShareAlike 4.0 International
License, which allows others to remix, tweak, and build upon the work
non-commercially, as long as appropriate credit is given and the new creations
are licensed under the identical terms.
Corresponding Author: Dr. Eugene Alex Joshua,
Associate consultant, Department of Critical Care Medicine and
Toxicology, Meenakshi Mission Hospital and Research Center,
Madurai, Tamil Nadu, India. Email ID: eugenealexi@gmail.com
International Journal of Medical Sciences and Nursing Research 2022;2(2):25-28 Page No: 25
Abstract
Article Summary: Submitted: 08-April-2022 Revised: 10-May-2022 Accepted: 02-June-2022 Published: 30-June-2022
The diagnosis of alveolar air leak syndrome was made based on
clinical examination and radiological imaging.
Ethical Approval:
This study was approved by the Institutional Review Board of
Meenakshi Mission Hospital and Research Center, Madurai, Tamil
Nadu, India. Participation in the study was voluntary and informed
consent was obtained prior to participation in the study. Anonymity
was maintained.
Joshua EA et al. Air Leak Syndrome and Coronavirus Disease 2019 (Covid-19) Pneumonia – A Case Series
International Journal of Medical Sciences and Nursing Research 2022;2(2):25-28 Page No: 26
Table 1: Distribution of baseline characteristics of Covid-19 patients
Case No
Age
Sex
Comorbidities
D Dimer
(ng/mL)
CRP
(mg/L)
Ferritin
(ng/mL)
IL-6
(pg/mL)
LDH
(IU/L)
1
61
M
HTN
1667
1.52
1807.90
20.46
688
2
52
F
Nil
579
13.80
4521
62.09
1579
3
65
F
Nil
782
9.50
199
67.34
777
4
51
M
CLL, DM
755
1.09
316
252.62
912
5
37
F
DM, HTN, RA
957
11.50
306.60
-
559
6
60
M
HTN
223
12.4
429
20.50
730
7
68
M
HTN
546
1.41
910.30
27.93
510
8
65
M
Nil
937
10.70
1722.50
89.66
937
9
38
M
Nil
482
1.73
1083.50
69.73
765
10
58
M
DM
1054.99
28.9
535.63
64
438
Table 2: Distribution of Air leak syndrome, type and clinical outcome among cases
Case No
Age/
Sex
Oxygen Delivery
Device
Lung
Involvement
Day of
Illness
Type
Outcome
1
61/M
HFNC, IMV
45%
Day 10
Subcutaneous Emphysema
Succumbed
2
52/F
NIV/IMV
40%
Day 18
Subcutaneous Emphysema,
Unilateral Pneumothorax
Succumbed
3
65/F
HFNC, NIV, IMV
80%
Day 24
Subcutaneous Emphysema,
Bilateral Pneumothorax
Succumbed
4
51/M
90%
HFM, HFNC
Day 24
Subcutaneous Emphysema,
Pneumomediastinum
Discharged
5
37/F
30%
HFM, NIV
Day 15
Subcutaneous Emphysema
Discharged
6
60/M
35%
HFM, NIV, IMV
Day 21
Subcutaneous Emphysema
Succumbed
7
68%
50%
FM, HFM,
HFNC
Day 21
Subcutaneous Emphysema,
Pneumomediastinum
Discharged
8
65/M
80%
HFM, NIV, IMV
Day 27
Subcutaneous Emphysema,
Pneumomediastinum, Bilateral
Pneumothorax
Succumbed
9
38/M
60%
NIV
Day 20
Subcutaneous Emphysema,
Unilateral Pneumothorax
Succumbed
10
58/M
80%
HFM, HFNC
Day 11
Subcutaneous Emphysema,
Pneumomediastinum
Discharged
Results:
Out of the 365 cases we analyzed, 10 cases developed either
subcutaneous emphysema, pneumomediastinum or pneumothorax.
The incidence rate was 2.73% per 1000 population. All patients had
comparable baseline characteristics. None of the patients had any pre-
existing chronic respiratory conditions like chronic obstructive
pulmonary disease (COPD), Pulmonary Tuberculosis, Interstitial lung
disease, etc. We could not find any correlation between air leak
syndrome and any of the inflammatory markers.
Joshua EA et al. Air Leak Syndrome and Coronavirus Disease 2019 (Covid-19) Pneumonia – A Case Series
All cases were diagnosed by clinical examination and radiological
imaging, chest Xray and HRCT whenever possible. None of the 10
patients were on invasive mechanical ventilation before developing
air leak syndrome. No one had undergone an invasive procedure like
central venous cannulation, intubation or bronchoscopy prior to the
onset of air leak. So iatrogenic cause was ruled out. All 10 cases had
developed air leak syndrome after 10 days of illness. The mean day
of illness when one or more manifestations of air leak syndrome was
diagnosed was 19.1. Of the 10 cases, 3 patients developed isolated
subcutaneous emphysema and 3 patients developed subcutaneous
emphysema and pneumomediastinum. The remaining 4 patients
developed pneumothorax 24 to 48 after subcutaneous emphysema
was diagnosed. These 4 patients required placement of intercostal
drainage tubes, intubation and mechanical ventilation. 6 of the 10
patients died during the course of illness. But the cause of death was
not directly related to the air leak syndrome. 2 patients were
discharged after a full recovery and 1 patient was discharged against
medical advice.
Discussion:
Many reviews on case reports and case series have brought to the fore
the association of air leak syndrome with COVID-19 pneumonia. [3
– 5] Almost identical cases were reported during Severe Acute
Respiratory Syndrome (SARS) and Middle East Respiratory
Syndrome (MERS) epidemic. [6] part of these publications focus
attention on the occurrence of spontaneous air leak syndrome in
patients not receiving invasive mechanical ventilation. The
phenomenon is not clear that, whether the diffuse alveolar damage
caused by these viruses predisposes the alveoli to undergo rupture
leading to air leak. The most common risk factors for alveolar air
leak syndrome are positive pressure ventilation, blunt chest trauma,
esophageal perforation, connective tissue disorders, smoking, cocaine
abuse and pre-existing chronic obstructive and restrictive lung
disease. [7] No one of our patients had any of these predisposing
conditions.
According to the theories proposed in the Macklin Effect [8] as
described in 1939 by Charles C. Macklin. During his experimental
studies on cats, Macklin noticed that artificially over distending the
lungs causes alveolar wall rupture and leakage of air. This air then
dissects along the sheaths surrounding the pulmonic blood vessels
and reaches the hilum from where it dissects in to the tissue planes of
mediastinum and the neck. In patients with ARDS, alveolar over
distension has been well described in patients undergoing invasive
mechanical ventilation with conventional large tidal volume due to
ventilator induced lung injury (VILI). No patients were on invasive
mechanical ventilation at the time of developing air leak syndrome.
This gives credence to the concept of Patient Self Inflicted Lung
Injury (P-SILI). [9] The large swings in transpulmonary pressure
during non-invasive ventilation, large tidal volumes generated due to
the relatively high lung compliance, coughing on a tight-fitting NIV
mask and mucus plugging can all cause increased intra alveolar
pressure and alveolar rupture. [10 – 11]
Pulmonary vascular thrombosis causing parenchymal and pleural
International Journal of Medical Sciences and Nursing Research 2022;2(2):25-28 Page No: 27
infarction has been proposed as a reason for air leak syndrome. All
our cases had elevated D-Dimer values. One patient had a CT
pulmonary angiogram due to clinical suspicion which ruled out any
major or minor pulmonary thromboembolism. While other cases did
not undergo a computed tomography by cause of risks involved in
transport. There was no echocardiographic evidence of pulmonary
thromboembolism or peripheral deep venous thrombosis. This shows
there is a complex interplay of various factors causing alveolar
rupture and air leak.
Conclusion:
This case series shows that air leak syndrome can develop in COVID-
19 patients receiving oxygenation through NIV and HFNC. This
should be ruled out whenever there is any sudden clinical
deterioration. Patients who develop subcutaneous emphysema and
pneumomediastinum should be carefully monitored for signs of
pneumothorax which can be life threatening in a sick patient with
borderline oxygenation.
Source of funding: This research did not receive any specific
grant from funding agencies. No incentives was given to the study
participants.
Conflict of Interest: The Authors reports no conflict of interest.
Acknowledgment: The Authors would like to thank all the
patients who has participated in this study for their cooperation and
support.
Authors’ Contributions: EAJ, KS, RJ, AKS, KR conceived
the study concept, design, analysed and interpreted the data, draft
manuscript, Reviewed and revised the full manuscript.
Here, EAJ- Eugene Alex Joshua, KS – Karthikeyan sellamuthu, RJ –
Rajesh Jeyaprakash; AKS – Anand Khushvinder Singh, KR –
Kanagalakshmi Rameshkumar, CK – Chandrakala Sankarapandian.
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Joshua EA et al. Air Leak Syndrome and Coronavirus Disease 2019 (Covid-19) Pneumonia – A Case Series
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