Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019

Abstract

Spanish Investigators on Emergency Situations Team (SIESTA) Network * BACKGROUND: Recent reports of patients with coronavirus disease 2019 developing pneumothorax correspond mainly to case reports describing mechanically ventilated patients. The real incidence, clinical characteristics, and outcome of spontaneous pneumothorax (SP) as a form of COVID-19 presentation remain to be defined. RESEARCH QUESTION: Do the incidence, risk factors, clinical characteristics, and outcomes of SP in patients with COVID-19 attending EDs differ compared with COVID-19 patients without SP and non-COVID-19 patients with SP?STUDY DESIGN AND METHODS: This case-control study retrospectively reviewed all patients with COVID-19 diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs) and compared them with two control groups: COVID-19 patients without SP and non-COVID-19 patients with SP. The relative frequencies of SP were estimated in COVID-19 and non-COVID-19 patients in the ED, and annual standardized incidences were estimated for both populations. Comparisons between case subjects and control subjects included 52 clinical, analytical, and radiologic characteristics and four outcomes. RESULTS:We identified 40 occurrences of SP in 71,904 patients with COVID-19 attending EDs (0.56&; 95% CI, 0.40&-0.76&). This relative frequency was higher than that among non-COVID-19 patients (387 of 1,358,134, 0.28&; 95% CI, 0.26&-0.32&; OR, 1.93; 95% CI, 1.41-2.71). The standardized incidence of SP was also higher in patients with COVID-19 (34.2 vs 8.2/100,000/year; OR, 4.19; 95% CI, 3.64-4.81). Compared with COVID-19 patients without SP, COVID-19 patients developing SP more frequently had dyspnea and chest pain, low pulse oximetry readings, tachypnea, and increased leukocyte count. Compared with non-COVID-19 patients with SP, case subjects differed in 19 clinical variables, the most prominent being a higher frequency of dysgeusia/ anosmia, headache, diarrhea, fever, and lymphopenia (all with OR > 10). All the outcomes measured, including in-hospital death, were worse in case subjects than in both control groups.INTERPRETATION: SP as a form of COVID-19 presentation at the ED is unusual (< 1& cases) but is more frequent than in the non-COVID-19 population and could be associated with worse outcomes than SP in non-COVID-19 patients and COVID-19 patients without SP.

The incidence, clinical characteristics, and outcomes of pneumothorax in hospitalized COVID-19 patients: A systematic review

“…No difference in the incidence of concomitant pneumomediastinum diagnosis between COVID-19 patients with pneumothoraces and non-COVID-19 patients with pneumothoraces (16.2% vs. 3.2%; P > 0.05) according to a case-control study by Miro et al. 14 Other occult signs of pneumothorax are subcutaneous emphysema; however, this may not be clinically apparent, especially in the absence of co-existing pneumomediastinum. Up to 56% of hospitalized COVID-19 patients with concomitant pneumomediastinum and pneumothorax developed subcutaneous emphysema as oppose to 30% in those with solely a radiologic finding of pneumothorax.…”

“…The two case-control studies by McGuinness et al and Miro et al had quality scores of seven and six, respectively ( Table 2 ). 13 , 14 In the five cohort studies, Ekanem et al and Martinelli et al had quality scores of eight and seven, respectively. 15 , 16 However, Cates et al, Ding et al, and Guo et al had quality scores of five, individually.…”

“… 13 The largest study included was a multi-center, case-control study by Miro et al conducted in Spain that described 71,904 COVID-19 patients who were initially assessed in the emergency departments (ED) with a reported incidence of pneumothoraces at 0.06%. 14 No COVID-19 patients required IMV prior to the diagnosis of pneumothorax. The second-largest study was a multi-center, retrospective cohort study by Cates et al that assessed 3,948 COVID-19 patients treated in the veteran affairs (VA) hospitals across the USA with a reported incidence of pneumothorax at 0.6%.…”

“… 14 , 15 , 16 , 19 , 20 According to three observational studies, less than 20% of hospitalized COVID-19 patients developed pneumomediastinum concurrently with pneumothoraces ( Table 1 ). 14 , 16 , 19 …”

Thrombotic complications in 2928 patients with COVID-19 treated in intensive care: a systematic review

“…Currently the exact prevalence of thrombosis in ICU-admitted patients with COVID-19 remains uncertain and in particular, whether this is sufficiently addressed by pharmacological thromboprophylaxis. Other published reviews of thrombotic complications associated with COVID-19, to date, have not specifically examined the rate of thrombotic complications in ICU-treated patients with COVID-19, nor the role of systematic screening for VTE in this cohort [ 11 – 17 ]. The aim of this systematic review was to identify the rate of thrombotic complications in patients with COVID-19 admitted to ICU to inform recommendations for diagnosis and management.…”