Pneumomediastinum bei schwerer COVID-19-Erkrankung: eine Fallserie von acht Patienten

Zusammenfassung

Die häufigste Ursache für ein Pneumomediastinum sind Traumata. Im Rahmen von COVID-19-Pneumonien wird dieses Krankheitsbild jedoch häufiger bei Patienten ohne zugrunde liegende exogene Verletzung gefunden. Pathophysiologisch wird hier eine Ursache analog zum Macklin-Effekt vermutet, bei dem Einrisse auf Alveolarebene zu Emphysemen entlang des Tracheobronchialbaums mit Betonung im Mediastinum führen. Wir stellen hier eine Fallserie von 8 Patienten vor, die auf unserer Intensivstation behandelt wurden. Bei allen Patienten konnte das Mediastinalemphysem bereits im Röntgenbild des Thorax gesehen werden. Fünf Patienten erhielten zusätzlich eine Computertomografie des Thorax. Sechs Patienten waren invasiv beatmet. Alle Patienten erhielten Kortikosteroide, Antikoagulation und Antibiose. Nur bei Patienten mit einem zusätzlichen Pneumothorax (n = 5) wurde eine Pleuradrainage angelegt. Eine Bronchoskopie wurde nur durchgeführt, falls im Zusammenhang mit dem Auftreten des Pneumomediastinums der Verdacht auf eine iatrogene Verletzung des Tracheobronchialbaums bestand (n = 2). Drei Patienten verstarben im Verlauf der Intensivbehandlung im Rahmen der COVID-19-Erkrankung. Ein prognostischer Zusammenhang zwischen dem Auftreten eines Pneumomediastinums und einem fatalen Krankheitsverlauf wird diskutiert.

Abstract

The most common cause of pneumomediastinum is trauma. However, in the context of COVID-19 pneumonia, this clinical picture is more often found in patients without underlying exogenous injury. Pathophysiologically, a cause analogous to the Macklin effect is suspected here, in which tears at the alveolar level lead to emphysema along the tracheobronchial tree with concentrating in the mediastinum. Here we present a case series of eight patients who were treated in our intensive care unit. In all patients, mediastinal emphysema could already be seen in the chest X-ray. Five patients also received a computed tomography scan of the thorax. Six patients had invasive ventilation. All patients received corticosteroids, anticoagulation and antibiotics. Pleural drainage was applied only in patients with an additional pneumothorax (n = 5). Bronchoscopy was performed only if there was a suspicion of iatrogenic injury to the tracheobronchial tree in relation to the appearance of the pneumomediastinum (n = 2). Three patients died during intensive care as part of the COVID-19 disease. A prognostic relationship between the occurrence of a pneumomediastinum and a fatal course of the disease is discussed.

Schlüsselwörter

Pneumomediastinum - COVID-19 - Pneumothorax - Weichteilemphysem - Thoraxdrainage - Macklin-Effekt

Keywords

pneumomediastinum - COVID-19 - pneumothorax - subcutaneous emphysema - chest tube - Macklin effect

Publication History

Received: 25 August 2021

Accepted after revision: 06 October 2021

Article published online:
06 December 2021

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