Pulmonary Barotrauma in COVID-19 Patients: Invasive versus Noninvasive Positive Pressure Ventilation

Shadi Hamouri,1 Shaher M Samrah,2 Omar Albawaih,1 Zidan Saleh,2 Mahmoud M Smadi,3 Ahmad Alhazymeh,1 Sebawe Syaj1 1Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science and Technology, King Abdullah University Hospital, Irbid, 22110, Jordan; 2Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, King Abdullah University Hospital, Irbid, 22110, Jordan; 3Department of Mathematics and Statistics, Faculty of Science and Art, Jordan University of Science and Technology, Irbid, 22110, JordanCorrespondence: Shadi HamouriDepartment of General Surgery and Urology, Faculty of Medicine, Jordan University of Science and Technology, King Abdullah University Hospital, P. O. Box 3030, Irbid, 22110, JordanTel +962 79 6266693Fax +962-2-7095010Email smhamouri@just.edu.joPurpose: This study aims to determine the incidence and outcome of COVID-19 patients who required positive pressure ventilation (PPV) and subsequently developed pulmonary barotrauma (PBT). Also, to investigate the risk factors and predictors of these complications to better understand the disease pathogenesis.Patients and Methods: This retrospective analysis enrolled all adult COVID-19 patients admitted through the period from October 1, 2020, to December 31, 2020. All patients who received any form of PPV were included. Patients were then divided into two groups based on PBT development, including subcutaneous emphysema, pneumothorax, and pneumomediastinum. Medical records of all patients were reviewed. Patients’ demographics, laboratory data on admission, respiratory support modes, surgical interventions, and outcomes were collected and analyzed.Results: In the specified period, 1095 patients were hospitalized due to COVID-19 illness. A total of 239 (21.8%) of all admitted patients received PPV. PBT accounted for 21.3% (51/239) of the study cohort. While both groups were equally exposed to the same modes of PPV, receiving invasive ventilation significantly correlated with decreased PBT odds (OR = 0.891; 95% CI, 0.803– 0.988; p=0.029). PBT patients were significantly younger (p< 0.001). Diabetes mellitus was found to have a protective effect on developing PBT (OR = 0.867; 95% CI, 0.782– 0.962), while PO2/FIO2 ratio was inversely associated with higher odds of developing PBT in both univariate and multivariate analyses (p=0.03 and p=0.019, respectively).Conclusion: COVID-19-infected patients are at a higher risk of developing PBT. Invasive positive pressure ventilation was associated with less PBT compared to noninvasive ventilation and delaying intubation does not seem to reduce the risk of pulmonary barotrauma.Keywords: COVID-19, pulmonary barotrauma, pneumothorax, pneumomediastinum, positive pressure ventilation, adult respiratory distress syndrome