Massive isolated pneumomediastinum in a ventilated patient with COVID-19 pneumonia managed with the insertion of a novel mediastinal drain

Spontaneous pneumomediastinum is associated with SARS-CoV-2 infection-related respiratory manifestations. Coexistence of pneumomediastinum with severe pneumonia may interfere with providing mechanical ventilation due to the possibility of the development of tension inside the mediastinum. We describe a case of severe COVID-19 pneumonia with spontaneous pneumomediastinum and subcutaneous emphysema who required mechanical ventilation. A novel drain was inserted into the mediastinum to decompress the large pneumomediastinum. A 47-year-old male with severe COVID-19 pneumonia required invasive ventilation due to respiratory failure. With the commencement of invasive ventilation, the patient developed a large pneumomediastinum with extensive subcutaneous emphysema. With the deterioration of COVID-19 pneumonia, it was necessary to increase respiratory parameters but was limited because of the possibility of tension pneumomediastinum. Two different drains were inserted, one to the subcutaneous space and the other to the mediastinum. A fenestrated suction drain with an outer protective sheath was created using a 24 Fr chest drain tube and a temporary peritoneal dialysis catheter increment of positive end-expiratory pressure was limited by the risk of development of tension pneumomediastinum. After the procedure, the patient slowly improved over the next few days. After 7 days of the procedure, the patient succumbed due to a secondary bacterial infection of the lung. This case report highlights that a simple technique using easily available equipment improves the condition and can assist in the escalation of ventilatory support in patients with pneumomediastinum.