{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,26]],"date-time":"2025-12-26T01:25:46Z","timestamp":1766712346120,"version":"build-2065373602"},"reference-count":32,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2021,11,29]],"date-time":"2021-11-29T00:00:00Z","timestamp":1638144000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>(1) Background: COVID-19 is a novel cause of acute respiratory distress syndrome (ARDS). Indeed, with the increase of ARDS cases due to the COVID-19 pandemic, there has also been an increase in the incidence of cases with pneumothorax (PNX) and pneumomediastinum (PNM). However, the incidence and the predictors of PNX\/PMN in these patients are currently unclear and even conflicting. (2) Methods: The present observational study analyzed the incidence of barotrauma (PNX\/PNM) in COVID-19 patients with moderate\u2013severe ARDS hospitalized in a year of the pandemic, also focusing on the three waves occurring during the year, and treated with positive-pressure ventilation (PPV). We collected demographic and clinical data. (3) Results: During this period, 40 patients developed PNX\/PNM. The overall incidence of barotrauma in all COVID-19 patients hospitalized in a year was 1.6%, and in those with moderate\u2013severe ARDS in PPV was 7.2% and 3.8 events per 1000 positive-pressure ventilator days. The incidence of barotrauma in moderate\u2013severe ARDS COVID-19 patients during the three waves was 7.8%, 7.4%, and 8.7%, respectively. Treatment with noninvasive respiratory support alone was associated with an incidence of barotrauma of 9.1% and 2.6 events per 1000 noninvasive ventilator days, of which 95% were admitted to the ICU after the event, due to a worsening of respiratory parameters. The incidence of barotrauma of ICU COVID-19 patients in invasive ventilation over a year was 5.8% and 2.7 events per 1000 invasive ventilator days. There was no significant difference in demographics and clinical features between the barotrauma and non-barotrauma group. The mortality was higher in the barotrauma group (17 patients died, 47.2%) than in the non-barotrauma group (170 patients died, 37%), although this difference was not statistically significant (p = 0.429). (4) Conclusions: The incidence of PNX\/PNM in moderate\u2013severe ARDS COVID-19 patients did not differ significantly between the three waves over a year, and does not appear to be very different from that in ARDS patients in the pre-COVID era. The barotrauma does not appear to significantly increase mortality in COVID-19 patients with moderate\u2013severe ARDS if protective ventilation strategies are applied. Attention should be paid to the risk of barotrauma in COVID-19 patients in noninvasive ventilation because the event increases the probability of admission to the intensive care unit (ICU) and intubation.<\/jats:p>","DOI":"10.3390\/jcm10235608","type":"journal-article","created":{"date-parts":[[2021,12,1]],"date-time":"2021-12-01T01:43:22Z","timestamp":1638323002000},"page":"5608","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Incidence of Pneumothorax and Pneumomediastinum in 497 COVID-19 Patients with Moderate\u2013Severe ARDS over a Year of the Pandemic: An Observational Study in an Italian Third Level COVID-19 Hospital"],"prefix":"10.3390","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2906-4855","authenticated-orcid":false,"given":"Nardi","family":"Tetaj","sequence":"first","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gabriele","family":"Garotto","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5115-709X","authenticated-orcid":false,"given":"Fabrizio","family":"Albarello","sequence":"additional","affiliation":[{"name":"Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Annelisa","family":"Mastrobattista","sequence":"additional","affiliation":[{"name":"Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0606-6353","authenticated-orcid":false,"given":"Micaela","family":"Maritti","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giulia Valeria","family":"Stazi","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria Cristina","family":"Marini","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ilaria","family":"Caravella","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manuela","family":"Macchione","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giada","family":"De Angelis","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Donatella","family":"Busso","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rachele","family":"Di Lorenzo","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Silvana","family":"Scarcia","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anna","family":"Farina","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6566-9838","authenticated-orcid":false,"given":"Daniele","family":"Centanni","sequence":"additional","affiliation":[{"name":"Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joel","family":"Vargas","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martina","family":"Savino","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alessandro","family":"Carucci","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrea","family":"Antinori","sequence":"additional","affiliation":[{"name":"Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8184-6291","authenticated-orcid":false,"given":"Fabrizio","family":"Palmieri","sequence":"additional","affiliation":[{"name":"Respiratory Infectious Diseases Unit, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gianpiero","family":"D\u2019Offizi","sequence":"additional","affiliation":[{"name":"Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stefania","family":"Ianniello","sequence":"additional","affiliation":[{"name":"Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fabrizio","family":"Taglietti","sequence":"additional","affiliation":[{"name":"Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7275-7358","authenticated-orcid":false,"given":"Paolo","family":"Campioni","sequence":"additional","affiliation":[{"name":"Department of Radiology and Diagnostic Imaging, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Francesco","family":"Vaia","sequence":"additional","affiliation":[{"name":"Health Direction, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5606-8712","authenticated-orcid":false,"given":"Emanuele","family":"Nicastri","sequence":"additional","affiliation":[{"name":"Clinical and Research Department of Infectious Diseases, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8182-5896","authenticated-orcid":false,"given":"Enrico","family":"Girardi","sequence":"additional","affiliation":[{"name":"Scientific Direction, National Institute for Infectious Diseases IRCCS Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Luisa","family":"Marchioni","sequence":"additional","affiliation":[{"name":"UOC Resuscitation, Intensive and Sub-Intensive Care, National Institute for Infectious Diseases IRCCS, Lazzaro Spallanzani, 00149 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"name":"ICU COVID-19 Study Group","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,29]]},"reference":[{"key":"ref_1","unstructured":"WHO (2020). Coronavirus Disease (COVID-19) Dashboard, WHO."},{"key":"ref_2","unstructured":"World Health Organization (WHO) (2020). Infection Prevention and Control Guidance for Long-Term Care Facilities in the Context of COVID-19, World Health Organisation."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"767","DOI":"10.1007\/s11739-020-02370-8","article-title":"Flowchart for Non-Invasive Ventilation Support in COVID-19 Patients from a Northern Italy Emergency Department","volume":"15","author":"Privitera","year":"2020","journal-title":"Intern. Emerg. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"E761","DOI":"10.1503\/cmaj.202661","article-title":"Sanjay Mehta Diagnosis and Management of Acute Respiratory Distress Syndrome in a Time of COVID-19","volume":"193","author":"Kassirian","year":"2021","journal-title":"CMAJ"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1080\/17476348.2018.1457954","article-title":"Ventilator-Induced Lung Injury during Controlled Ventilation in Patients with Acute Respiratory Distress Syndrome: Less Is Probably Better","volume":"12","author":"Cruz","year":"2018","journal-title":"Expert Rev. Respir. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"92","DOI":"10.4187\/respcare.05752","article-title":"The Role of Rescue Therapies in the Treatment of Severe ARDS","volume":"63","author":"Alessandri","year":"2018","journal-title":"Respir. Care"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"3642","DOI":"10.1053\/j.jvca.2021.02.008","article-title":"Predictors of Pneumothorax\/Pneumomediastinum in Mechanically Ventilated COVID-19 Patients","volume":"35","author":"Belletti","year":"2021","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2017","DOI":"10.2147\/IJGM.S314155","article-title":"Pulmonary Barotrauma in COVID-19 Patients: Invasive versus Noninvasive Positive Pressure Ventilation","volume":"14","author":"Hamouri","year":"2021","journal-title":"Int. J. Gen. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e0210","DOI":"10.1097\/CCE.0000000000000210","article-title":"Subcutaneous Emphysema, Pneumomediastinum, and Pneumothorax in Critically Ill Patients with Coronavirus Disease 2019: A Retrospective Cohort Study","volume":"2","author":"Jones","year":"2020","journal-title":"Crit. Care Explor."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"E252","DOI":"10.1148\/radiol.2020202352","article-title":"Increased Incidence of Barotrauma in Patients with COVID-19 on Invasive Mechanical Ventilation","volume":"297","author":"McGuinness","year":"2020","journal-title":"Radiology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"6129","DOI":"10.1007\/s00330-020-06975-7","article-title":"CT in Coronavirus Disease 2019 (COVID-19): A Systematic Review of Chest CT Findings in 4410 Adult Patients","volume":"30","author":"Ojha","year":"2020","journal-title":"Eur. Radiol."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Akdogan, R.E., Mohammed, T., Syeda, A., Jiwa, N., Ibrahim, O., and Mutneja, R. (2021). Pneumothorax in Mechanically Ventilated Patients with COVID-19 Infection. Case Rep. Crit. Care, 2021.","DOI":"10.1155\/2021\/6657533"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Martinelli, A.W., Ingle, T., Newman, J., Nadeem, I., Jackson, K., Lane, N.D., Melhorn, J., Davies, H.E., Rostron, A.J., and Adeni, A. (2020). COVID-19 and Pneumothorax: A Multicentre Retrospective Case Series. Eur. Respir. J., 56.","DOI":"10.1183\/13993003.02697-2020"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1016\/j.csm.2004.03.007","article-title":"Pneumothorax and Pneumomediastinum","volume":"23","author":"Putukian","year":"2004","journal-title":"Clin. Sports Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1573","DOI":"10.1007\/s00134-012-2682-1","article-title":"The Berlin Definition of ARDS: An Expanded Rationale, Justification, and Supplementary Material","volume":"38","author":"Ferguson","year":"2012","journal-title":"Intensive Care Med."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Griffiths, M.J.D., McAuley, D.F., Perkins, G.D., Barrett, N., Blackwood, B., Boyle, A., Chee, N., Connolly, B., Dark, P., and Finney, S. (2019). Guidelines on the Management of Acute Respiratory Distress Syndrome. BMJ Open Respir. Res., 6.","DOI":"10.1136\/bmjresp-2019-000420"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"637","DOI":"10.1001\/jama.299.6.637","article-title":"Ventilation Strategy Using Low Tidal Volumes, Recruitment Maneuvers, and High Positive End-Expiratory Pressure for Acute Lung Injury and Acute Respiratory Distress Syndrome: A Randomized Controlled Trial","volume":"299","author":"Meade","year":"2008","journal-title":"JAMA -J. Am. Med Assoc."},{"key":"ref_18","first-page":"183","article-title":"Lung Ultrasound in the Critically Ill","volume":"30","author":"Lichtenstein","year":"2014","journal-title":"Ann. Intensive Care"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1807","DOI":"10.1093\/infdis\/jiaa578","article-title":"Postmortem Findings in Italian Patients with COVID-19: A Descriptive Full Autopsy Study of Cases with and without Comorbidities","volume":"222","author":"Falasca","year":"2020","journal-title":"J. Infect. Dis."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2005","DOI":"10.3201\/eid2609.202095","article-title":"Pathology and Pathogenesis of SARS-CoV-2 Associated with Fatal Coronavirus Disease, United States","volume":"26","author":"Martines","year":"2020","journal-title":"Emerg. Infect. Dis."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1378\/chest.120.2.543","article-title":"The Macklin Effect: A Frequent Etiology for Pneumomediastinum in Severe Blunt Chest Trauma","volume":"120","author":"Wintermark","year":"2001","journal-title":"Chest"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"759","DOI":"10.1007\/s11739-015-1229-1","article-title":"Spontaneous Pneumomediastinum Due to the Macklin Effect: Less Is More","volume":"10","author":"Chassagnon","year":"2015","journal-title":"Intern. Emerg. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1241","DOI":"10.1016\/j.chest.2020.11.013","article-title":"Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019","volume":"159","year":"2021","journal-title":"Chest"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"91","DOI":"10.4081\/monaldi.2021.1608","article-title":"Pneumothorax and Pneumomediastinum in COVID-19 Acute Respiratory Distress Syndrome","volume":"91","author":"Lal","year":"2021","journal-title":"Monaldi Arch. Chest Dis."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1014","DOI":"10.23736\/S0375-9393.19.13418-9","article-title":"Patient Self-Inflicted Lung Injury: Implications for Acute Hypoxemic Respiratory Failure and ARDS Patients on Non-Invasive Support","volume":"85","author":"Grieco","year":"2019","journal-title":"Minerva Anestesiol."},{"key":"ref_26","first-page":"547","article-title":"Acute Respiratory Distress Syndrome and Pneumonia","volume":"62","author":"Terzi","year":"2013","journal-title":"Jpn. J. Anesthesiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"106464","DOI":"10.1016\/j.rmed.2021.106464","article-title":"Pneumothorax in Critically Ill Patients with COVID-19 Infection: Incidence, Clinical Characteristics and Outcomes in a Case Control Multicenter Study","volume":"184","author":"Chopra","year":"2021","journal-title":"Respir. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"106552","DOI":"10.1016\/j.rmed.2021.106552","article-title":"Pneumothorax and Barotrauma in Invasively Ventilated Patients with COVID-19","volume":"187","author":"Belletti","year":"2021","journal-title":"Respir. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"678","DOI":"10.1378\/chest.122.2.678","article-title":"Pneumothorax in the ICU: Patient Outcomes and Prognostic Factors","volume":"122","author":"Chen","year":"2002","journal-title":"Chest"},{"key":"ref_30","first-page":"1","article-title":"Pneumothorax in the Intensive Care Unit: Retrospective Analysis of Two Years\u2019 Experience","volume":"5","author":"Sevdi","year":"2019","journal-title":"Bagcilar Med Bull."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1111\/j.1399-6576.2011.02602.x","article-title":"Outcome of Spontaneous and Iatrogenic Pneumothoraces Managed with Small-Bore Chest Tubes","volume":"56","author":"Galbois","year":"2012","journal-title":"Acta Anaesthesiol. Scand."},{"key":"ref_32","first-page":"221","article-title":"Pneumothorax in the Intensive Care Unit: Incidence, Risk Factors, and Outcome","volume":"50","year":"2006","journal-title":"Anesthesiology"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/23\/5608\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:37:10Z","timestamp":1760168230000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/23\/5608"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,29]]},"references-count":32,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2021,12]]}},"alternative-id":["jcm10235608"],"URL":"https:\/\/doi.org\/10.3390\/jcm10235608","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2021,11,29]]}}}