Patient 1
A 52-year-old male with a past medical history of diabetes and asthma, was admitted with dyspnoea, fever and cough. Blood gas levels on admission revealed type-1 respiratory failure and he was placed on non-invasive ventilation with continuous positive airway pressure (CPAP) (PEEP of 5 FiO2 0.5). His chest radiograph (CXR) on admission demonstrated bilateral mid-zone and basal ground glass opacification typical of moderately severe COVID-19 pneumonia. He was admitted to a medical ward and antibiotics were administered (Co-amoxiclav and Doxycycline). The diagnosis of COVID-19 was confirmed by reverse transcription polymerase chain reaction (RT-PCR). His ventilation requirements gradually increased over 6 days, to a PEEP of 14 and a FiO2 of 0.8. Further deterioration resulted in him requiring intubation and mechanical ventilation. CXR following intubation revealed extensive bilateral consolidation and moderate pneumomediastinum. He was placed in a prone position and commenced on Epoprostenol nebulizers, therapeutic anticoagulation and Meropenem. The following day, a CXR demonstrated extensive pneumomediastinum, compressing the adjacent lung tissue, subcutaneous emphysema over the lower neck and upper chest but no pneumothorax. A subsequent computed tomography (CT) scan additionally demonstrated extensive pneumoretroperitoneum encasing the left kidney and pancreas. There was no indication of bowel or oesophageal perforation and the distribution of air was suggestive of extension from the chest. His extensive pneumomediastinum was managed conservatively with monitoring by daily CXRs where gradual improvement was observed. He continued to improve and was eventually discharged to the ward requiring no surgical intervention.