Pneumatocele and mediastinal emphysema preceding bilateral pneumothorax during airway pressure release ventilation

A 63-year-old man was admitted to intensive care unit due to acute respiratory distress syndrome (ARDS). During treatment of lymphoma, he developed bacterial pneumonia. Several days later, severe ARDS was developed; his PaO₂/FiO₂ (P/F) ratio was about 80. He was intubated and managed with airway pressure release ventilation (APRV) of 27 cmH₂O high positive end expiratory pressure (PEEP). CT scan was performed to evaluate lung lesions, 5 days later. In this CT, new pneumatocele and mediastinal emphysema were identified incidentally (Figures 1,2). APRV of 27 cmH₂O high PEEP was continued for poor oxygenation, even though there were signs indicating barotrauma. Right pneumothorax emerged in the next day (Figure 3) and half-day later, left pneumothorax followed (Figure 4).

Figure 1 Mediastinal emphysema (6 days after start of MV).

Figure 2 Pneumatocele (6 days after start of MV).

Figure 3 Right pneumothorax (7 days after start of MV).

Figure 4 Left pneumothorax (7 days after start of MV).

Pneumothorax is one of the most concerned complications of APRV. Newly identified pneumatocele or mediastinum emphysema during APRV management may imply to occurrence of pneumothorax. It would be better to decrease airway pressure or patient’s inspiratory pressure in case.

Acknowledgments

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Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jeccm.2020.02.01). The authors have no conflicts of interest to declare.

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