"Barotrauma in Admitted Covid-19 Cases - A Single Center Retrospective Study"
Condition: Barotrauma; COVID-19
MeSH terms: COVID-19; Barotrauma
Study type: Observational

Summary: 
      A retrospective study is planned to find out the incidence and association type of
      respiratory support with barotrauma in Covid-19 cases admitted in Sultan Qaboos University
      Hospital. As widely known, Covid-19 affects the respiratory system primarily and is the main
      cause of admission to hospital. Depending upon the severity, different levels of respiratory
      support are offered to the patients. Normally patients with viral/bacterial respiratory
      diseases have a low incidence of barotrauma. Since this disease is new and it has been
      observed that a significant number of covid-19 patients develop barotrauma, hence it is
      deemed worthwhile to investigate the matter.

      All the patients admitted to the ward, high dependency unit, and intensive care unit will be
      scanned and those who developed barotrauma (pneumothorax, surgical emphysema,
      pneumo-pericardium, and pneumo-mediastinum) will be studied in detail and analyzed.

      This review is expected to highlight the problem and etiology and we might be able to suggest
      a management strategy to deal with this problem.
    

Detailed description: 
      Introduction

      Covid-19 is a recently emerged disease affecting the respiratory system primarily but later
      on, progresses to multisystem involvement. Most of the cases are mild and self-remitting.
      However, those who develop moderate to severe symptoms require admission. They receive
      different modalities of respiratory support as per the international guidelines.

      The covid-19 typically starts with mild respiratory symptoms with fever, headache, and
      myalgia. Most of the cases remit after these by 10 days, but around 15% progress to more
      severe symptoms such as worsening of fever, respiratory symptoms leading to hypoxemia
      proceeding to complications further on. Correspondingly, the radiological findings peak by 2
      weeks after symptom onset. By this point in time, the patients start requiring respiratory
      support and complications start to emerge as the time passes. Bacterial superinfections,
      interleukin surge, septic shock are commonly encountered. Recently, at our center rising
      episodes of barotrauma have been observed.

      In the covid era because of huge numbers of admissions, the hospital, as well as ICU beds
      with respiratory and monitoring resources, are becoming significantly scarce (4). Hence
      prevention of complications can have a great impact on improving patient outcomes and
      utilizing hospital resources.

      There can be few recognized mechanisms of barotrauma in Covid-19 cases. One of them is
      alveolar overdistension leading to rupture and barotrauma and the second is a decrease in the
      caliber of pulmonary vessels increasing pressure gradient causing air leak to the sheath.
      Positive pressure ventilation leads to an increase in intra-alveolar alveoli. Macklin
      phenomenon also describes the occurrence of a large pressure gradient between marginal
      alveoli and lung interstitium leading to barotrauma (5).

      Barotrauma is treated by intercostal drain insertion, as well as conservative management by
      the reduction in airway pressures and increase in oxygen supplementation. Both these can lead
      to setbacks in a patient's recovery.

      This research will identify the etiology of barotrauma and will highlight the preventive
      strategy to deal with it.

      Aim of the Study:

      This study aims to examine the incidence of barotrauma, its association with different
      management strategies so as to suggest modification of preventive and inciting factors. This
      may improve patient outcomes and conserve hospital resources.

      Specific objectives:

        1. To study the incidence of barotrauma in hospitalized Covid-19 cases.

        2. To find the association of factors inciting barotrauma.

        3. To formulate a management plan for the prevention of barotrauma in these cases.

      Methodology and study design:

      This retrospective study will be conducted in the Department of Anesthesia and ICU at Sultan
      Qaboos University hospital (SQUH) situated in Muscat, Oman. All admitted patients of
      Covid-19/SARS-2 between March 2020 to April 2021 will be scanned in the computerized system
      with the keywords: barotrauma, pneumothorax, surgical emphysema, pneumo-pericardium, and
      pneumo-mediastinum. A list of cases with these problems will be obtained and the cases will
      be studied in detail. Data will be obtained from SQUH "Track Care" hospital information
      system.

      Study Population:

      Inclusions:

      ● All admitted patients of Covid-19/SARS-2 between March 2020 to April 2021 t SQUH

      Exclusions:

      ● Patients who develop barotrauma due to central line insertion or trauma prior to admission.

      Data Collection and Analyses:

      Demographic details, Day of barotrauma, comorbidities, type of respiratory support, other
      treatment modalities, and covid laboratory profile: ferritin, LDH, CRP, IL-6, fibrinogen,
      white cell count, and lymphocyte counts.

      SPSS software (version 23) will be used to collect and analyze data. Obtaining the
      significance of association will be through using students' t-test, fisher's exact test, and
      Chi-square test. P-value < 0.05 will be considered significant.
    

Observational model: Case-Control
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        A total of 2159 Covid-19 PCR-positive patients were identified in consecutive participant
        sampling at the University hospital during the study period. Out of these 63 patients were
        found to develop barotrauma. Matched controls were identified and a total of 322 cases was
        scanned. 61 patients were discharged from the emergency department after initial treatment,
        1 patient left against medical advice and 2 patients died before they could be admitted to
        the ward and 7 were shifted to other hospitals, and their follow-up was lost, hence a total
        of 251 patients were finally studied. 63 patients were "Cases" and 188 were "Controls" in
        the ratio of 1:3 cases: controls.
      
Keywords: Barotrauma; COVID-19; positive pressure ventilation; ferritin; steroids