Highlights
- •Macklin is a radiological sign consisting in air dissecting peribronchial sheaths.
- •Macklin sign is often detected on chest CT scan in patients with barotrauma.
- •Link between Macklin and barotrauma is described in various ways in literature.
- •Recent studies proposed Macklin as an accurate predictor of barotrauma.
- •Macklin could identify patient at risk for barotrauma, to try to prevent it.
Abstract
Introduction
Recent studies suggested that Macklin sign is a predictor of barotrauma in patients
with acute respiratory distress syndrome (ARDS). We performed a systematic review
to further characterize the clinical role of Macklin.
Methods
PubMed, Scopus, Cochrane Central Register and Embase were searched for studies reporting
data on Macklin. Studies without data on chest CT, pediatric studies, non-human and
cadaver studies, case reports and series including <5 patients were excluded. The
primary objective was to assess the number of patients with Macklin sign and barotrauma.
Secondary objectives were: occurrence of Macklin in different populations, clinical
use of Macklin, prognostic impact of Macklin.
Results
Seven studies enrolling 979 patients were included. Macklin was present in 4–22% of
COVID-19 patients. It was associated with barotrauma in 124/138 (89.8%) of cases.
Macklin sign preceded barotrauma in 65/69 cases (94.2%) 3–8 days in advance. Four
studies used Macklin as pathophysiological explanation for barotrauma, two studies
as a predictor of barotrauma and one as a decision-making tool. Two studies suggested
that Macklin is a strong predictor of barotrauma in ARDS patients and one study used
Macklin sign to candidate high-risk ARDS patients to awake extracorporeal membrane
oxygenation (ECMO). A possible correlation between Macklin and worse prognosis was
suggested in two studies on COVID-19 and blunt chest trauma.
Conclusions
Increasing evidence suggests that Macklin sign anticipate barotrauma in patients with
ARDS and there are initial reports on use of Macklin as a decision-making tool. Further
studies investigating the role of Macklin sign in ARDS are justified.
Graphical abstract
Graphical Abstract
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Respiratory MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Spontaneous pneumomediastinum and Macklin effect: overview and appearance on computed tomography.World J. Radiol. 2014; 6: 850-854https://doi.org/10.4329/wjr.v6.i11.850
- Pneumothorax with massive collapse from experimental local over-inflation of the lung substance.Can. Med. Assoc. J. 1937; 36: 414-420
- Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: clinical implications.Arch. Intern. Med. 1939; 64: 913-926https://doi.org/10.1001/archinte.1939.00190050019003
- Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: an interpretation of the clinical literature in the light of laboratory experiment.Med (United States). 1944; 23: 281-358
- Pneumomediastinum in blunt chest trauma: a case report and review of the literature.Case Rep Emerg Med. 2014; 2014685381https://doi.org/10.1155/2014/685381
- The Macklin effect: a frequent etiology for pneumomediastinum in severe blunt chest trauma.Chest. 2001; 120: 543-547https://doi.org/10.1378/CHEST.120.2.543
- Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients.Intensive Care Med. 2004; 30: 612-619https://doi.org/10.1007/s00134-004-2187-7
- Barotrauma in coronavirus disease 2019 patients undergoing invasive mechanical ventilation: a systematic literature review.Crit. Care Med. 2022; 50: 491-500https://doi.org/10.1097/CCM.0000000000005283
- Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: the Macklin effect.Heart Lung. 2010; 39: 444-447https://doi.org/10.1016/J.HRTLNG.2009.10.001
- Spontaneous pneumomediastinum revealing asthma: the Macklin effect.Cureus. 2022; 14e24978https://doi.org/10.7759/CUREUS.24978
- Anorexia nervosa with massive pulmonary air leak and extraordinary propagation.Int. J. Eat. Disord. 2017; 50: 451-453https://doi.org/10.1002/EAT.22674
- Pneumomediastinum revisited.Radiographics. 2000; 20: 1043-1057https://doi.org/10.1148/RADIOGRAPHICS.20.4.G00JL131043
- Spontaneous pneumomediastinum as a complication of a COVID-19 related pneumonia: case report and review of literature.Radiol Case Reports. 2020; 15: 2577-2581https://doi.org/10.1016/J.RADCR.2020.09.052
- Coronavirus disease 2019 with spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema.France. New Microbes New Infect. 2020; 38100785https://doi.org/10.1016/J.NMNI.2020.100785
- COVID-19 with spontaneous pneumomediastinum.Lancet Infect. Dis. 2020; 20: 510https://doi.org/10.1016/S1473-3099(20)30156-0
- Pneumothorax and barotrauma in invasively ventilated patients with COVID-19.Respir. Med. 2021; 187106552https://doi.org/10.1016/j.rmed.2021.106552
- Microvascular COVID-19 lung vessels obstructive thromboinflammatory syndrome (MicroCLOTS): an atypical acute respiratory distress syndrome working hypothesis.Crit Care Resusc. 2020; 22: 95-97https://doi.org/10.51893/2020.2.pov2
- Increased incidence of barotrauma in patients with COVID-19 on invasive mechanical ventilation.Radiology. 2020; 297: E252-E262https://doi.org/10.1148/RADIOL.2020202352
- Predictors of pneumothorax/pneumomediastinum in mechanically ventilated COVID-19 patients.J. Cardiothorac. Vasc. Anesth. 2021; 35: 3642-3651https://doi.org/10.1053/j.jvca.2021.02.008
- A radiological predictor for pneumomediastinum/pneumothorax in COVID-19 ARDS patients.J. Crit. Care. 2021; 66: 14-19https://doi.org/10.1016/j.jcrc.2021.07.022
- Macklin effect on baseline chest CT scan accurately predicts barotrauma in COVID-19 patients.Respir. Med. 2022; 197106853https://doi.org/10.1016/J.RMED.2022.106853
- PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews.BMJ. 2021; 372: n160https://doi.org/10.1136/bmj.n160
- The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.BMJ. 2021; 372: n71https://doi.org/10.1136/bmj.n71
- Frequent cause of the Macklin effect in spontaneous pneumomediastinum: demonstration by multidetector-row computed tomography.J. Comput. Assist. Tomogr. 2006; 30: 92-94https://doi.org/10.1097/01.RCT.0000187416.07698.8D
- Pneumomediastinum in COVID-19 disease: outcomes and relation to the Macklin effect.Asian Cardiovasc. Thorac. Ann. 2021; 29: 541-548https://doi.org/10.1177/02184923211010089
- Venovenous extracorporeal membrane oxygenation in awake non-intubated patients with COVID-19 ARDS at high risk for barotrauma.J. Cardiothorac. Vasc. Anesth. 2022; 36: 2975-2982https://doi.org/10.1053/J.JVCA.2022.03.011
- Diagnosis and treatment of patients with spontaneous pneumomediastinum.Respir Investig. 2014; 52: 36-40https://doi.org/10.1016/J.RESINV.2013.06.001
- Spontaneous pneumomediastinum diagnosed by the Macklin effect.J. Surg. Case Rep. 2022; 2022: rjab634https://doi.org/10.1093/JSCR/RJAB634
- Clinical analysis of spontaneous pneumomediastinum.Tuberc. Respir. Dis. 2012; 73: 169-173https://doi.org/10.4046/TRD.2012.73.3.169
- Spontaneous pneumomediastinum: time for consensus.N. Am. J. Med. Sci. 2013; 5: 460-464https://doi.org/10.4103/1947-2714.117296
- Spontaneous pneumomediastinum.Ann. Thorac. Surg. 2004; 78: 711-713https://doi.org/10.1016/j.athoracsur.2003.09.021
- Spontaneous pneumomediastinum in COVID-19: the Macklin effect?.Am. J. Respir. Crit. Care Med. 2021; 204: 989-990https://doi.org/10.1164/RCCM.202105-1179IM
- Spontaneous pneumomediastinum and COVID-19 pneumonia: report of three cases with emphasis on CT imaging.Radiol Case Reports. 2021; 16: 2586-2592https://doi.org/10.1016/J.RADCR.2021.06.040
- Cervical soft tissue emphysema in hanging--a prospective autopsy study.J. Forensic Sci. 2012; 57: 132-135https://doi.org/10.1111/J.1556-4029.2011.01911.X
- A fire extinguisher death: the Macklin effect.Am. J. Forensic Med. Pathol. 2018; 39: 103-105https://doi.org/10.1097/PAF.0000000000000374
- Pulmonary barotrauma in COVID-19: a systematic review and meta-analysis.Ann Med Surg. 2022; 73103221https://doi.org/10.1016/J.AMSU.2021.103221
- The incidence, clinical characteristics, and outcomes of pneumothorax in hospitalized COVID-19 patients: a systematic review.Heart Lung. 2021; 50: 599-608https://doi.org/10.1016/J.HRTLNG.2021.04.005
- Pulmonary air leak in COVID-19: time to learn from our mistakes.Intensive Care Med. 2022; 48: 1614-1616https://doi.org/10.1007/s00134-022-06866-z
- Efecto Macklin como predictor radiológico precoz de barotrauma en pacientes COVID-19 con SDRA en ventilación mecánica invasiva.Med Intensiva. Published online September. 2022; 6https://doi.org/10.1016/J.MEDIN.2022.07.003
- Air leak, barotrauma susceptibility, and imaging in acute respiratory distress syndrome: novel application of an old tool.Intensive Care Med. 2022; 48: 1837-1838https://doi.org/10.1007/S00134-022-06902-Y
- An increasing rate of pneumomediastinum in non-intubated COVID-19 patients: the role of steroids and a possible radiological predictor.Respir Investig. 2022; 60: 865-867https://doi.org/10.1016/J.RESINV.2022.06.012
- Patient-self inflicted lung injury: a practical review.J. Clin. Med. 2021; 10: 2738https://doi.org/10.3390/JCM10122738
- Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives.Intensive Care Med. 2016; 42: 1360-1373https://doi.org/10.1007/S00134-016-4400-X
- P-SILI in critically ill COVID-19 patients: Macklin effect and the choice of noninvasive ventilatory support type.Crit. Care. 2023; 27: 38https://doi.org/10.1186/S13054-023-04313-Z
- Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis.Lancet Respir. Med. 2022; 10: 573-583https://doi.org/10.1016/S2213-2600(22)00043-1
- Awake proning as an adjunctive therapy for refractory hypoxemia in non-intubated patients with COVID-19 acute respiratory failure: guidance from an international group of healthcare workers.Am. J. Trop. Med. Hyg. 2021; 104: 1676-1686https://doi.org/10.4269/ajtmh.20-1445
- Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit.JAMA. 2020; 323: 2338-2340https://doi.org/10.1001/jama.2020.7861
- Effect of lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal vs standard care ventilation on 90-day mortality in patients with acute hypoxemic respiratory failure: the REST randomized clinical trial.JAMA. 2021; 326: 1013-1023https://doi.org/10.1001/JAMA.2021.13374
- Effect of lung recruitment and titrated Positive End-Expiratory Pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome - a randomized clinical trial.JAMA. 2017; 318: 1335-1345https://doi.org/10.1001/jama.2017.14171
- Ventilatory-associated barotrauma in COVID-19 patients: a multicenter observational case control study (COVI-mix study).Pulmonology. Published online November. 2022; https://doi.org/10.1016/J.PULMOE.2022.11.002
Article info
Publication history
Published online: February 27, 2023
Accepted:
February 27,
2023
Received in revised form:
February 26,
2023
Received:
November 23,
2022
Identification
Copyright
© 2023 Elsevier Ltd. All rights reserved.
