Management of Barotrauma from Coughing
Barotrauma from coughing should be managed with rapid recompression when severe, along with supportive care including oxygen therapy, cough suppressants, and mucolytics to prevent further injury and complications. 1
Pathophysiology and Presentation
- Barotrauma from coughing occurs when excessive transpulmonary pressure causes alveolar rupture, leading to air leakage into surrounding tissues 1
- Common manifestations include pneumothorax, pneumomediastinum, subcutaneous emphysema, and in severe cases, arterial gas embolism 1, 2
- Patients with less distensible lungs and airways are at higher risk of developing barotrauma from coughing due to increased elastic stresses in peribronchial alveolar tissue 1
Initial Management
Oxygen Therapy
- Provide supplemental oxygen to maintain SpO₂ >92% while preparing for definitive management 3
- Use caution with high-flow oxygen therapy as it may increase risk of worsening barotrauma 4, 5
Medication Management
- Cough suppressants such as dextromethorphan to reduce the impulse to cough and prevent further barotrauma 6
- Mucolytics like guaifenesin to loosen phlegm and thin bronchial secretions, making coughs more productive and potentially less forceful 7
- Consider short-term corticosteroid therapy for reducing inflammation, especially if there's evidence of laryngeal edema 4
Management Based on Severity
Mild to Moderate Cases
- Supportive care with oxygen therapy and medications as described above 4, 2
- Avoid sedating medications before securing the airway in patients with respiratory distress, as they may compromise compensatory mechanisms 3
Severe Cases
- Rapid recompression is recommended for severe barotrauma and may improve prognosis 1, 2
- For pneumothorax, chest tube insertion may be required, especially if tension pneumothorax develops 1, 8
- In cases of arterial gas embolism, hyperbaric oxygen therapy may be indicated 2
Special Considerations
Mechanical Ventilation (If Required)
- Use lung-protective ventilation strategies to prevent further barotrauma 1, 8
- Limit tidal volumes to 6-8 mL/kg and peak airway pressures to <30 cm H₂O 1
- Employ permissive hypercapnia (pH >7.2) if necessary to avoid excessive airway pressures 1
- Prolong expiratory time by shortening inspiratory time and reducing minute volume 1
Prevention of Recurrence
- Address underlying causes of excessive coughing 1
- Patients with a history of barotrauma should have this documented prominently in their medical records 3
- Recurrent barotrauma tends to be more severe than the original incident, emphasizing the importance of prevention 1
Monitoring and Follow-up
- Close monitoring of respiratory status is essential as residual airway edema may persist 3
- Consider CT scanning to identify subpleural blebs or cysts that may not be evident on plain radiographs 1
- Pulmonary function testing may be valuable in assessing risk of recurrence, particularly focusing on flow rates at low lung volumes 1