Elsevier

Journal of Critical Care

Volume 66, December 2021, Pages 14-19
Journal of Critical Care

A radiological predictor for pneumomediastinum/pneumothorax in COVID-19 ARDS patients

https://doi.org/10.1016/j.jcrc.2021.07.022Get rights and content

Highlights

  • Macklin effect can be regarded as an early detector of lung frailty.

  • Macklin effect accurately predicts barotrauma in COVID-19 ARDS patients.

  • Median delay between Macklin effect first evidence and barotrauma onset was 8.5 days.

  • Patients with Macklin effect might benefit from ultraprotective ventilation strategy.

Abstract

Purpose

To determine whether Macklin effect (a linear collection of air contiguous to the bronchovascular sheath) on baseline CT imaging is an accurate predictor for subsequent pneumomediastinum (PMD)/pneumothorax (PNX) development in invasively ventilated patients with COVID-19-related acute respiratory distress syndrome (ARDS).

Materials and methods

This is an observational, case-control study. From a prospectively acquired database, all consecutive invasively ventilated COVID-19 ARDS patients who underwent at least one baseline chest CT scan during the study time period (February 25th, 2020–December 31st, 2020) were identified; those who had tracheal lesion or already had PMD/PNX at the time of the first available chest imaging were excluded.

Results

37/173 (21.4%) patients enrolled had PMD/PNX; specifically, 20 (11.5%) had PMD, 10 (5.8%) PNX, 7 (4%) both. 33/37 patients with subsequent PMD/PNX had Macklin effect on baseline CT (89.2%, true positives) 8.5 days [range, 1–18] before the first actual radiological evidence of PMD/PNX. Conversely, 6/136 patients without PMD/PNX (4.4%, false positives) demonstrated Macklin effect (p < 0.001). Macklin effect yielded a sensitivity of 89.2% (95% confidence interval [CI]: 74.6–96.9), a specificity of 95.6% (95% CI: 90.6–98.4), a positive predictive value (PV) of 84.5% (95% CI: 71.3–92.3), a negative PV of 97.1% (95% CI: 74.6–96.9) and an accuracy of 94.2% (95% CI: 89.6–97.2) in predicting PMD/PNX (AUC:0.924).

Conclusions

Macklin effect accurately predicts, 8.5 days in advance, PMD/PNX development in COVID-19 ARDS patients.

Keywords

Acute respiratory distress syndrome
Mechanical ventilation
Tomography, X-ray computed
Pneumothorax
Pneumomediastinum
COVID-19

Abbreviations

ARDS
acute respiratory distress syndrome
COVID-19
coronavirus disease 2019
LR
likelihood ratio
NPV
negative predictive value
PMD
pneumomediastinum
PNX
pneumothorax
PPV
positive predictive value

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1

A complete list of COVID-BioB Study Group investigators is presented below and in the Supplementary Appendix.

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