In the context of the severe respiratory disease associated with COVID-19, it is highly likely that (unless there is a history of retching/vomiting) the pathogenesis of the pneumomediastinum is due to alveolar rupture secondary to barotrauma associated with mechanical ventilation, due to the high PEEP required to maintain adequate oxygenation in these severely compromised patients. Indeed, barotrauma is a recognized complication of mechanical ventilation [5]. Tracheobronchial injury secondary to intubation can also be a cause. In order to try and minimize the risk of barotrauma, patients should be ventilated with the least damaging settings possible to achieve adequate oxygenation. In patients requiring escalating PEEP, efforts should be focussed on identifying potentially reversible causes and strategies to reduce the PEEP should be sought, for example proning the patients early.