SARS Cov-2 Infection-Related Persistent Air Leaks Managed By Endobronchial Valves

Abstract

Introduction:There have been recently documented reports of pneumothorax and persistent air leaks as complications associated with SARS CoV-2-related ARDS. Alveolar-pleural fistulas and broncho-pleural fistulas can lead to the development of pneumothorax. In more recent times, bronchoscopy-guided interventions, specifically Endobronchial Valves (EBV), have been established to serve as a treatment modality for these fistulas. In this case series, we present the first two cases of persistent pneumothorax and persistent air leak related to COVID-19 that were managed successfully with EBV placement.Case description: Case 1-A 44-year-old female was admitted for acute hypoxic respiratory failure secondary to COVID-19 pneumonia requiring invasive mechanical ventilation. Immediate post-intubation imaging found a large right-sided pneumothorax that required emergent insertion of a chest tube. Repeat chest imaging showed worsening pneumothorax requiring additional chest tubes; however, air leaks persisted. Subsequent chest imaging showed the possibility of a fistula near the right upper lobe bronchus. Bronchoscopy-guided placement of Endobronchial Valves was performed, and follow-up imaging showed resolution of pneumothorax and improvement in clinical symptoms. Case 2-A 48-year-old male with a recent admission for COVID-19 pneumonia was diagnosed with large leftsided hydropneumothorax. A chest tube was placed and put to suction; however, it failed multiple water seal trials. Bronchoscopy with endobronchial valve placement was performed over segments of the left upper lobe. Repeat chest imaging showed the complete resolution of pneumothorax. Conclusions:The current literature review describes only a few cases of COVID-19 related to BPF or APF. In both described cases, the diagnosis of PALs was made within 4-6 weeks of COVID-19 infection. The first case developed pneumothorax following mechanical ventilation. The etiology of the development of BPF, in this case, may be secondary to barotrauma. The second case was incidentally diagnosed with hydropneumothorax four weeks after the initial COVID infection that had not needed mechanical ventilation. This prompts the likelihood of multiple etiologies that can lead to the development of fistulas in patients with recent COVID-19 disease. Bronchoscopy is the gold standard in the management of PALs. Fistulas secondary to inflammatory processes, like a necrotizing infection, are better managed with an endobronchial intervention as lung parenchyma is too friable for surgical intervention. Recent literature has demonstrated that endobronchial valves are an effective, minimally invasive intervention for patients with PALs. We report two of the first few cases of COVID-19 complicated by PALs that were successfully managed with EBV placement. Our data search reveals six reported cases of COVID-19 that eventually developed PAL and managed with the placement of EBV and resulted in the successful resolution of the air leaks.