COVID-19 and pneumothorax: a multicentre retrospective case series

Abstract

IntroductionPneumothorax and pneumomediastinum have both been noted to complicate cases of COVID-19 requiring hospital admission. We report the largest case series yet described of patients with both these pathologies that includes non-ventilated patients.MethodsCases were collected retrospectively from UK hospitals with inclusion criteria limited to a diagnosis of COVID-19 and the presence of either pneumothorax or pneumomediastinum. Patients included in the study presented between March and June 2020. Details obtained from the medical record included demographics, radiology, laboratory investigations, clinical management and survival.ResultsSeventy-one patients from 16 centres were included in the study, of whom 60 patients had pneumothoraces (six also with pneumomediastinum), whilst 11 patients had pneumomediastinum alone. Two of these patients had two distinct episodes of pneumothorax, occurring bilaterally in sequential fashion, bringing the total number of pneumothoraces included to 62. Clinical scenarios included patients who had presented to hospital with pneumothorax, patients who had developed pneumothorax or pneumomediastinum during their inpatient admission with COVID-19 and patients who developed their complication whilst intubated and ventilated, either with or without concurrent extracorporeal membrane oxygenation. Survival at 28 days was not significantly different following pneumothorax (63.1%±6.5%) or isolated pneumomediastinum (53.0%±18.7%; p=0.854). The incidence of pneumothorax was higher in males. The 28-day survival was not different between the sexes (males 62.5%±7.7% versus females 68.4%±10.7%; p=0.619). Patients above the age of 70 had a significantly lower 28-day survival than younger individuals (≥70 years 41.7%±13.5% survival versus <70 years 70.9%±6.8% survival; p=0.018 log-rank).ConclusionThese cases suggest that pneumothorax is a complication of COVID-19. Pneumothorax does not seem to be an independent marker of poor prognosis and we encourage active treatment to be continued where clinically possible.

Pneumothorax in COVID-19 Acute Respiratory Distress Syndrome: Case Series

“…Our findings are different from the recently published ERS case series, which demonstrated a 63.1% overall survival of COVID-19 patients with pneumothorax [ 10 ]. They concluded that their data did not support previous suggestions that the development of pneumothorax is a grave prognostic marker.…”

“…Observational studies reported the occurrence of pneumothorax in 20-34% of patients with SARS-CoV-1 who required mechanical ventilation [ 7 , 8 ]. There have been case reports of pneumothorax associated with COVID-19 ARDS, as well as a recently published multicenter retrospective case series in the United Kingdom [ 9 , 10 ]. Here we report the largest case series of pneumothorax in this patient population and describe their clinical characteristics and outcomes.…”

Pneumothorax and Pneumatocoele Formation in a Patient with COVID-19: a Case Report

“…An association between COVID-19 and pneumothorax has been described, but the mechanisms underlying this association have yet to be elaborated. Martinelli et al who co-ordinated a recent multicentre study (the largest series described in the literature to date) analysing this clinical scenario conclude that the relative frequency of this co-presentation of pathologies indicates that it is unlikely to be coincidental [ 13 ]. While it has been previously suggested that the development of pneumothorax may correlate with disease progression [ 6 ], the above study by Martinelli et al suggests that it does not seem to be a marker of poor prognosis in this setting, and the authors encourage active treatment where clinically possible.…”

“…Aiolfi et al, in a paper outlining their approach to the surgical management of COVID-19 patients with pneumothorax, attribute the occurrence of pneumothorax in these patients to a combination decreased lung compliance (due to the histological changes described above) and sustained pressure ventilation, which they postulate results in rupture of pre-existing blebs [ 2 ]. It is felt, however, that barotrauma alone cannot account for the co-occurrence of pneumothorax in COVID-19 infection [ 13 ]. Liu et al described two reports of cystic lung disease in COVID-19 patients—one of whom suffered pneumothorax—the authors suggest that the fibromyxoid exudates which develop in this infection can predispose to pneumothorax through pressure differentials resulting from a ball/valve mechanism within airways and airspaces [ 14 ].…”

“…This case—including Figs. 1b , 2b and 3a —has been included in a case series which has recently been accepted for publication [ 13 ]. Permission was sought—and granted—from the European Respiratory Journal to include the images in question in this case report.…”