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Tension pneumomediastinum in patients with COVID-19
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  • Published on:
    Response to eLetter “What is the mechanism of pneumomediastinum?”.
    • Alessio Campisi, Thoracic Surgeon Thoracic Surgery Unit, G.B. Morgagni-L. Pierantoni Hospital, University of Bologna, Forlì.
    • Other Contributors:
      • Venerino Poletti, Pulmonologist
      • Angelo Paolo Ciarrocchi, Thoracic surgeon
      • Maurizio Salvi, Thoracic Surgeon
      • Franco Stella, Thoracic Surgeon

    Dear Editor,

    We would like to thank Dr. Klepikov for his interest in our article [1], despite his dispute of the pathophysiology we presented. As it may be clearly understood from the article, our purpose was to present a relatively rare clinical case represented by a tension pneumomediastinum and not to evaluate its underlying pathophysiological mechanism. In our experience, this clinical scenario is extremely rare to face in a general thoracic surgery unit, but it has become more frequent in the last year due to SARS-CoV2 pandemic and the frequent use of high volume invasive ventilation in these patients [2,3]. The article [1] focuses on the most important aspects of the clinical case from the mechanical ventilation to the surgical therapy briefly mentioning the most likely mechanism of the origin of pneumomediastinum according to the peer-reviewed literature at hand [3,4]. As one can imagine an extensive and in-depth analysis of the pathophysiology of pneumomediastinum would be a difficult task to undertake in an article with a 500-word limit which aims to present our treatment of the condition.
    According to literature [2,3,4], different hypotheses have been proposed to explain the pathophysiology underlying spontaneous pneumomediastinum, but the most accepted one has been described by Macklin and Macklin [5]. The presence of a pressure gradient between the alveoli and the lung interstitium results in alveolar rupture and, if the pressure gradient is mainta...

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    Conflict of Interest:
    None declared.
  • Published on:
    What is the mechanism of pneumomediastinum?
    • Igor Klepikov, surgeon, pediatric surgeon, retired MD,professor,retired

    Short comment to the article:
    Campisi A, Poletti V, Ciarrocchi AP, et al. (2020). Tension pneumomediastinum in patients with COVID-19. Thorax 2020; 75:1130-1131.
    Igor Klepikov*
    The authors describe a relatively rare complication that usually accompanies various diseases of the respiratory system and can significantly worsen the condition of patients. The fact that this complication occurs not only in patients with lung ventilation problems, but even in women in labor (1) suggests that an important trigger factor for this phenomenon is sudden attacks of increased intra-bronchial pressure. Such a sudden increase in air pressure in a confined space, according to Pascal's law (2), spreads evenly in all directions and can create an air flow to the surrounding tissues, damaging the weakest or previously damaged tissues.
    However, free air in the mediastinum has a clear anatomical localization, and its appearance is due to tissue damage in the area that has a common anatomical space and a free communication with the Central intra-thoracic space. In this regard, the mechanism of air penetration into the mediastinal fiber, which is described by the authors (3), automatically borrowing it from the assumptions of other researchers (4), looks, from my point of view, fantastic, far from real conditions.
    First of all, there is no objective evidence that air enters the mediastinum through the perivascular spaces as a result of damage...

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    Conflict of Interest:
    None declared.