Pneumomediastinum and Spontaneous Subcutaneous Emphysema in COVID-19 Patients Using High-Flow Nasal Cannula (HFNC)

Rizki Suhadayanti, Arie Zainul Fatoni, Wiwi Jaya, Aswoco Andyk Asmoro


Background: Spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema are rare complications that occur without mechanical ventilation, namely 0.81% of all COVID-19 patients. During the COVID-19 pandemic, high-flow nasal cannulas (HFNC) were used to support respiratory failure in critically ill patients. However, there have been no clinical trials explaining its safety and effectiveness. Hypoxemic normocapnic respiratory failure is an indicator of HFNC use. This study reports a case of associated spontaneous subcutaneous pneumomediastinum and emphysema in a COVID-19 patient using HFNC.

Case: A 30-year-old male patient came to the hospital with a chief complaint of increasingly severe shortness of breath and confirmed COVID-19. Physical examination revealed a good airway, spontaneous breathing with a frequency of 28 times/minute; SpO2 of 97% with HFNC Flow 60 and FiO2 60%; blood pressure of 102/69 mmHg; and heart rate of 65 beats per minute. On the second day of treatment in the ICU, the patient did not experience desaturation or hypotension. Patent airway, spontaneous breathing, and oxygenation initiated using NRM 10lpm with a target SpO2 of 97%, RR at 30-32x/minute. On the fifth day, desaturation and hypotension were no longer observed.

Discussion: Real-Time Reverse Transcriptase (RT)–PCR Diagnostic Panel detects SARS-CoV-2 in respiratory samples. Chest CT scans show viral pneumonia. Subcutaneous emphysema (SE) and pneumomediastinum cause breathing issues. Severe COVID-19 is treated with antivirals, vitamins, and oxygen therapy. Pneumomediastinum or subcutaneous emphysema may occur due to prolonged non-invasive ventilation but is generally self-limited.

Conclusion: Clinical improvement was found in COVID-19 patients with pneumomediastinum and spontaneous subcutaneous emphysema using HFNC.


high flow nasal cannula, pneumomediastinum, spontaneous subcutaneous emphysema

Full Text:



Simioli F, Annunziata A, Polistina GE, Coppola A, Di Spirito V, Fiorentino G. The role of high flow nasal cannula in COVID-19 associated pneumomediastinum and pneumothorax. Healthcare (Basel). 2021;9(6):620.

Hazariwala V, Hadid H, Kirsch D, Big C. Spontaneous pneumomediastinum, pneumopericardium, pneumothorax and subcutaneous emphysema in patients with COVID-19 pneumonia, a case report. J Cardiothorac Surg. 2020;15(1):301.

Johns Hopkins University & Medicine. COVID-19 map [Internet]. Johns Hopkins University & Medicine. 2021 [cited 2022 Mar 14]. Available from:

Satuan Tugas Penanganan COVID-19. Peta sebaran COVID-19 [Internet]. Satuan Tugas Penanganan COVID-19. 2021 [cited 2022 Mar 14]. Available from:

Hamouri S, Alqudah M, Albawaih O, Al-Zoubi N, Syaj S. Spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in non-ventilated COVID-19 patients. Future Sci OA. 2021;8(2):FSO771.

Manna S, Maron SZ, Cedillo MA, Voutsinas N, Toussie D, Finkelstein M, et al. Spontaneous subcutaneous emphysema and pneumomediastinum in non-intubated patients with COVID-19. Clin Imaging. 2020;67:207–13.

Heijboer F, Oswald L, Cretier S, Braunstahl GJ. Pneumomediastinum in a patient with COVID-19 due to diffuse alveolar damage. BMJ Case Rep. 2021;14(5):e242527.

Irianto B, khairsyaf O, Russilawati. Pneumothorax and subcutaneous emphysema related to use of HFNC in critically ill COVID-19 patient. Jurnal Human Care. 2021;6(2):484–90.

Wadhawa R, Thakkar A, Chhanwal H, Bhalotra A, Rana Y, Wadhawa V. Spontaneous pneumomediastinum and subcutaneous emphysema in patients with COVID-19. Saudi J Anaesth. 2021;15(2):93–6.

Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, evaluation, and treatment of coronavirus (COVID-19) [Updated 2023 Aug 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Available from:

Di Gennaro F, Pizzol D, Marotta C, Antunes M, Racalbuto V, Veronese N, et al. Coronavirus diseases (COVID-19) current status and future perspectives: A narrative review. Int J Environ Res Public Health. 2020;17(8):2690.

Susilo A, Rumende CM, Pitoyo CW, Santoso WD, Yulianti M, Herikurniawan H, et al. Coronavirus disease 2019: Tinjauan literatur terkini. Jurnal Penyakit Dalam Indonesia. 2020;7(1):45–67.

Perhimpunan Dokter Paru Indonesia (PDPI), Perhimpunan Dokter Spesialis Kardiovaskular Indonesia, Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia, Perhimpunan Dokter Anestesiologi dan Terapi Intensif Indonesia, Ikatan Dokter Anak Indonesia. Pedoman tatalaksana COVID-19. Pedoman tatalaksana COVID-19 edisi 4. Indonesia; 2022.

Yuki K, Fujiogi M, Koutsogiannaki S. COVID-19 pathophysiology: A review. Clin Immunol. 2020;215:108427.



  • There are currently no refbacks.

Copyright (c) 2024 Rizki Suhadayanti, Arie Zainul Fatoni, Wiwi Jaya, Aswoco Andyk Asmoro


SINTA Garuda Indonesian Scientific Journal Database (ISJD) Indonesia One Search (IOS) Crossref

ROAD-ISSN Dimensions Google Scholar 


Jurnal Respirologi Indonesia
pISSN: 0853-7704 - eISSN: 2620-3162
Address: Jalan Cipinang Bunder No. 19, Cipinang, Pulogadung, Jakarta Timur, DKI Jakarta 13240, Indonesia
Phone: +62-21-2247-4845

An official publication by
the Indonesian Society of Respirology (ISR)

Creative Commons License
Creative Commons Attribution-NonCommercial 4.0 International License