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Id Subject Object Predicate Lexical cue
T1 0-76 Sentence denotes Pneumomediastinum in COVID-19 patients: a case series of a rare complication
T2 78-86 Sentence denotes Abstract
T3 87-95 Sentence denotes Abstract
T4 96-212 Sentence denotes Pneumomediastinum is a rare clinical finding, but one which can be the source of significant concern for clinicians.
T5 213-484 Sentence denotes By presenting 3 such cases, we highlight that pneumomediastinum can complicate the course of a severe coronavirus disease 2019 infection but emphasize that conservative management is the first-line method of treatment, with gradual resorption of the air from the tissues.
T6 485-577 Sentence denotes It is important to be alert to the development of pneumothorax, which will require drainage.
T7 579-591 Sentence denotes INTRODUCTION
T8 592-679 Sentence denotes Pneumomediastinum is a rare occurrence and commonly referred to a thoracic surgeon [1].
T9 680-957 Sentence denotes During the coronavirus disease 2019 (COVID-19) pandemic, we have observed an increased in the number of patients referred to us for pneumomediastinum, suggesting that there is an association with either the viral infection, or the ventilation required to manage these patients.
T10 958-1037 Sentence denotes Here we present 3 cases highlighting the management of these patients (Fig. 1).
T11 1039-1050 Sentence denotes CASE REPORT
T12 1052-1061 Sentence denotes Patient 1
T13 1062-1177 Sentence denotes A 52-year-old male with a past medical history of diabetes and asthma, was admitted with dyspnoea, fever and cough.
T14 1178-1359 Sentence denotes 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).
T15 1360-1517 Sentence denotes His chest radiograph (CXR) on admission demonstrated bilateral mid-zone and basal ground glass opacification typical of moderately severe COVID-19 pneumonia.
T16 1518-1617 Sentence denotes He was admitted to a medical ward and antibiotics were administered (Co-amoxiclav and Doxycycline).
T17 1618-1718 Sentence denotes The diagnosis of COVID-19 was confirmed by reverse transcription polymerase chain reaction (RT-PCR).
T18 1719-1815 Sentence denotes His ventilation requirements gradually increased over 6 days, to a PEEP of 14 and a FiO2 of 0.8.
T19 1816-1902 Sentence denotes Further deterioration resulted in him requiring intubation and mechanical ventilation.
T20 1903-2002 Sentence denotes CXR following intubation revealed extensive bilateral consolidation and moderate pneumomediastinum.
T21 2003-2121 Sentence denotes He was placed in a prone position and commenced on Epoprostenol nebulizers, therapeutic anticoagulation and Meropenem.
T22 2122-2306 Sentence denotes 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.
T23 2307-2446 Sentence denotes A subsequent computed tomography (CT) scan additionally demonstrated extensive pneumoretroperitoneum encasing the left kidney and pancreas.
T24 2447-2578 Sentence denotes There was no indication of bowel or oesophageal perforation and the distribution of air was suggestive of extension from the chest.
T25 2579-2707 Sentence denotes His extensive pneumomediastinum was managed conservatively with monitoring by daily CXRs where gradual improvement was observed.
T26 2708-2809 Sentence denotes He continued to improve and was eventually discharged to the ward requiring no surgical intervention.
T27 2811-2820 Sentence denotes Patient 2
T28 2821-2970 Sentence denotes A 68-year-old male with a past medical history of hypertension and hypercholesterolaemia, was admitted with a history of dyspnoea, myalgia and cough.
T29 2971-3118 Sentence denotes He was similarly found to have type-1 respiratory failure, CPAP was instituted (PEEP of 8 FiO2 0.4), and Co-Amoxiclav and Doxycycline administered.
T30 3119-3169 Sentence denotes The diagnosis of COVID-19 was confirmed by RT-PCR.
T31 3170-3307 Sentence denotes Over a period of 13 days, despite increased CPAP support, he continued to deteriorate and required intubation and mechanical ventilation.
T32 3308-3414 Sentence denotes Post-intubation CXR demonstrated bilateral pulmonary infiltrates and subcutaneous emphysema into the neck.
T33 3415-3594 Sentence denotes A subsequent CT scan demonstrated widespread pneumomediastinum with significant subcutaneous, retrocrural and retroperitoneal extensions, with no evidence of visceral perforation.
T34 3595-3718 Sentence denotes His oxygen requirements increased the following day and CXR demonstrated a new right-sided pneumothorax requiring drainage.
T35 3719-3812 Sentence denotes The patient clinically improved and serial CXR confirmed resolution of the pneumomediastinum.
T36 3814-3823 Sentence denotes Patient 3
T37 3824-4009 Sentence denotes A 66-year-old male with a past medical history of hypertension, obesity and chronic kidney disease, was admitted with fever and acute confusion, secondary to type 1 respiratory failure.
T38 4010-4079 Sentence denotes He was similarly managed initially with CPAP therapy and antibiotics.
T39 4080-4153 Sentence denotes Admission CXR demonstrated pulmonary infiltrates and a pneumopericardium.
T40 4154-4245 Sentence denotes He deteriorated rapidly and required intubation and mechanical ventilation on the same day.
T41 4246-4299 Sentence denotes Subsequent CXR confirmed extensive pneumomediastinum.
T42 4300-4383 Sentence denotes He suffered severe hyponatraemia and acute kidney injury requiring haemofiltration.
T43 4384-4434 Sentence denotes The diagnosis of COVID-19 was confirmed by RT-PCR.
T44 4435-4480 Sentence denotes He was extubated and transferred to the ward.
T45 4481-4542 Sentence denotes Serial CXR confirmed the resolution of his pneumomediastinum.
T46 4544-4554 Sentence denotes DISCUSSION
T47 4555-4694 Sentence denotes Pneumomediastinum is a rare clinical finding, but one which can be the source of significant concern for clinicians managing such patients.
T48 4695-4855 Sentence denotes By presenting these 3 cases, we emphasize that conservative management is usually all that is required, with gradual resorption of the air from the tissues [1].
T49 4856-5001 Sentence denotes There have been 2 other COVID-19 patients with pneumomediastinum described in the literature to date, who were also treated conservatively [2–4].
T50 5002-5202 Sentence denotes However, it is important to continue to monitor with serial imaging for the development of pneumothorax, which can lead to cardiorespiratory compromise, and also other signs of clinical deterioration.
T51 5203-5358 Sentence denotes In patients with an accompanying pneumothorax, chest drainage is indicated and if there is ongoing air leakage, this is an indication for thoracic surgery.
T52 5359-5743 Sentence denotes 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.
T53 5744-5822 Sentence denotes Indeed, barotrauma is a recognized complication of mechanical ventilation [5].
T54 5823-5891 Sentence denotes Tracheobronchial injury secondary to intubation can also be a cause.
T55 5892-6049 Sentence denotes In order to try and minimize the risk of barotrauma, patients should be ventilated with the least damaging settings possible to achieve adequate oxygenation.
T56 6050-6252 Sentence denotes 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.
T57 6253-6289 Sentence denotes Conflict of interest: none declared.
T58 6290-6299 Sentence denotes Figure 1:
T59 6301-6501 Sentence denotes Imaging highlighting pneumomediastinum. (A) Patient 1: chest radiograph and transverse computed tomography (CT) slice; (B) patient 2: coronal and transverse CT slices; (C) patient 3: chest radiograph.
T60 6502-6559 Sentence denotes Arrows highlight pneumomediastinum and pneumopericardium.
T61 6561-6581 Sentence denotes Reviewer information
T62 6582-6643 Sentence denotes European Journal of Cardio-Thoracic Surgery thanks Nikolay O.
T63 6644-6754 Sentence denotes Travin and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.