Management of Persistent Pneumothorax With Thoracoscopy and Bleb Resection in COVID-19 Patients. Ann Thorac Surg. 2020;110:e413-e415. [PMID: 32353441 PMCID: PMC7185014 DOI: 10.1016/j.athoracsur.2020.04.011]

Pneumomediastinum and pneumothorax in coronavirus disease-2019: Description of a case series and a matched cohort study

Objective

To describe the characteristics of COVID-19 patients with pneumothorax and pneumomediastinum (PTX/PM) and their association with patient outcomes.

Patients and methods

Adults admitted to five Mayo Clinic hospitals with COVID-19 between 03/2020-01/2022 were evaluated. PTX/PM was defined by imaging. Descriptive analyses and a matched (age, sex, admission month, COVID-19 severity) cohort comparison was performed. Hospital mortality, length of stay (LOS), and predisposing factors were assessed.

Results

Among 6663 patients, 197 had PTX/PM (3 %) (75 PM, 40 PTX, 82 both). The median age was 59, with 71 % males. Exposure to invasive and non-invasive mechanical ventilation and high-flow nasal cannula before PTX/PM were 42 %, 17 %, and 20 %, respectively. Among isolated PTX and PM/PTX patients 70 % and 53.7 % underwent an intervention, respectively, while 96 % of the PM-only group was followed conservatively.A total of 171 patients with PTX/PM were compared to 171 matched controls. PTX/PM patients had more underlying lung disease (40.9 vs. 23.4 %, p < 0.001) and lower median body mass index (BMI) (29.5 vs. 31.3 kg/m2, p = .007) than controls. Among patients with available data, PTX/PM patients had higher median positive end-expiratory and plateau pressures than controls; however, differences were not significant (10 vs. 8 cmH2O; p = 0.38 and 28 vs. 22 cmH2O; p = 0.11, respectively). PTX/PM patients had a higher odds of mortality (adjusted odds ratio [95%CI]: 3.37 [1.61-7.07]) and longer mean LOS (percent change [95%CI]: 39 [9-77]) than controls.

Conclusion

In COVID-19 patients with similar severity, PTX/PM patients had more underlying lung disease and lower BMI. They had significantly increased mortality and LOS.

Persistent air leak secondary to pneumothorax in COVID-19: A case report and review of literature

An air leak is a pathologic communication between an area of the endobronchial tree and the pleural space, causing continued air flow. The communication can originate from a distal portion of the airway, causing an alveolar-pleural fistula, or from a more proximal airway, causing a bronchopleural fistula. When the air leak persists beyond 5-7 days, it is classified as persistent air leak (PAL). PAL has serious implications on patient management and outcomes, such as prolonged chest tube maintenance, high rate of infections, ventilation-perfusion mismatch, and prolonged hospital stay with higher morbidity and mortality. There are currently no guidelines for the management of PAL in COVID-19 patients. We presented a case of PAL in a patient with COVID-19-associated pneumothorax successfully treated with a one-way endobronchial valve. We also reviewed current published cases of PAL secondary to COVID-19-associated pneumothorax and the various methods they were treated. The first line treatment was insertion of one or more chest tubes, but the persistence of an air leak then led to other treatment modalities. Initial early surgical evaluation followed by pleurodesis is recommended for the management of PAL. The most common surgical approaches include VATS or open thoracotomy with mechanical or chemical pleurodesis or pleurectomy. However, surgery is not always a feasible option for critically ill patients. In such cases, there are multiple less invasive options for the management of PAL, including implantable devices, such as Watanabe spigots and stents, and chemical agents, such as thermal treatments, hemostatic substances, and tissue adhesives.

COVID-19 and spontaneous pneumothorax: a survival analysis

INTRODUCTION

COVID-19 Patients may be at risk for involving with spontaneous pneumothorax. However, clinical data are lacking in this regard. In this study, we aimed to investigate the demographic, clinical, and radiological characteristics and survival predictors in COVID-19 patients with pneumothorax.

METHODS

This is a retrospectivestudy conducted on COVID-19 patients with pneumothorax that had been hospitalized at hospital. l from December 2021 to March 2022. The chest computed tomography (CT) scan of all patients was reviewed by an experienced pulmonologist in search of pulmonary pneumothorax. Survival analysis was conducted to identify the predictors of survival in patients with COVID-19 and pneumothorax.

RESULTS

A total of 67 patients with COVID-19 and pneumothorax were identified. Of these, 40.7% were located in the left lung, 40.7% were in the right lung, and 18.6% were found bilaterally. The most common symptoms in the patient with pneumothorax were dyspnea (65.7%), increased cough severity (53.7%), chest pain (25.4%), and hemoptysis (16.4%). The frequency of pulmonary left and right bullae, pleural effusion, andfungus ball were 22.4%, 22.4%, 22.4%, and 7.5%, respectively. Pneumothorax was managed with chest drain (80.6%), chest drain and surgery (6%), and conservatively (13.4%). The 50-day mortality rate was 52.2% (35 patients). The average survival time for deceased patients was 10.06 (2.17) days.

CONCLUSIONS

Our results demonstrated that those with pleural effusion or pulmonary bullae have a lower survival rate. Further studies are required to investigate the incidence and causality relation between COVID-19 and pneumothorax.

The prognostic effect of concomitant COVID-19 with spontaneous pneumothorax

Background

The aim of this study was to investigate the prevalence of novel coronavirus disease 2019 (COVID-19) in patients hospitalized with primary spontaneous pneumothorax and to evaluate its possible effects on the clinical course, treatment, and the prognosis.

Methods

Between April 2020 and January 2021, a total of 86 patients (78 males, 8 females; mean age: 27±5 years; range, 16 to 40 years) who had no underlying lung disease and were diagnosed with the first episode of spontaneous pneumothorax were retrospectively analyzed. At the same time of diagnosis, all patients were screened for COVID-19 via polymerase chain reaction test of nasopharyngeal swabs. According to the test results, the patients were divided into two groups as COVID-19(+) and COVID-19(-). The duration of air leak, hospital stay, recurrence rates and treatment modalities, and mortality rates of the two groups were compared.

Results

Following a pneumothorax diagnosis, 18 (21%) patients were diagnosed with COVID-19. In COVID-19(+) patients, the mean air leak and lung expansion duration were significantly longer (p<0.0001 for both). In these patients, the mean length of hospital stay was also significantly longer (p<0.0001). During the median follow-up of six months, no mortality was observed and the recurrence rate was similar between the two groups (p=0.998).

Conclusion

Our study results suggest that COVID-19 negatively affects the recovery time in patients with spontaneous pneumothorax.

Case of Spontaneous Pneumothorax After Recent COVID Pneumonia Hospitalization

An elderly man with COPD and heart failure was admitted to the Family Medicine Inpatient Service from the Emergency Department (ED) after experiencing acute onset of shortness of breath at home. He had recently been briefly hospitalized with COVID pneumonia. Upon arrival in the ED, he was requiring continuous positive airway pressure to maintain oxygen saturations. Overall, physical exam was notable for mild respiratory distress. Lab evaluation was unremarkable, but chest x-ray showed a right sided pneumothorax. Spontaneous pneumothoraces have been described in post-COVID cases, with COPD and mechanical ventilation thought to be risk factors. Treatment consists of supportive cares, needle decompression and thoracostomy if necessary. Providers should be aware of this rare albeit serious complication and monitor higher risk patients appropriately.

Negative-pressure wound therapy to treat thoracic empyema with COVID-19-related persistent air leaks: A case report

The novel coronavirus disease (COVID-19) has resulted in a global pandemic. Recently, COVID-19-related pneumothorax has gained attention because of the associated prolonged hospital stay and high mortality. While most cases of pneumothorax respond well to conservative and supportive care, some cases of refractory pneumothorax with persistent air leaks (PALs) do not respond to conventional therapies. There is a lack of evidence-based management strategies to this regard. We describe the case of a 73-year-old man with COVID-19-related acute respiratory distress syndrome (ARDS) who developed delayed tension pneumothorax with PALs caused by alveolopleural fistulas. Despite chest tube drainage, autologous blood pleurodesis, and endoscopic procedures, the PALs could not be closed, and were complicated by thoracic empyema. Subsequent minimally invasive open-window thoracostomy (OWT) with vacuum-assisted closure (VAC) therapy helped successfully control the refractory PALs. Serial chest computed tomography monitoring was useful for the early detection of the pneumothorax and understanding of its temporal relationship with air-filled lung cysts. Our case provides a new perspective to the underlying cause of refractory pneumothorax with PALs, secondary to COVID-19-related ARDS, and underscores the potential of OWT with VAC therapy as a therapeutic alternative in such cases.

Limitation of tube thoracostomy in treating pneumothorax in COVID-19 infected patients. A retrospective cohort study

Background

COVID¹⁹ infection is caused by the highly contagious SARS-CoV-2(Severe acute respiratory syndrome coronavirus 2). The first outbreak of this infection was in Wuhan, China in December 2019. Since then, it has spread rapidly across the world, with more than 100000 new cases each day. Among those infected with SARS-COV-2 up to 20% develop severe disease requiring hospitalization. Among those who are hospitalized, one quarter will need ICU admission. Admission to the ICU is due to respiratory failure or pneumonia. The pneumonia associated with COVID¹⁹ infection may lead to respiratory failure requiring endotracheal intubation and mechanical ventilation. An important complication of mechanical ventilation is barotrauma. Barotrauma appears to be common in COVID¹⁹ patients. Pneumothorax developed in 25% of COVID¹⁹ patients who had barotrauma. In COVID¹⁹ the percentage of patients with mild symptoms who develop a pleural effusion is 8% compared to 28% in patients who are critically ill. Most of the COVID¹⁹ infected that have a pneumothorax or pleural effusion need a thoracostomy. In trauma cases most, thoracic injuries (leading to pneumothorax or hemothorax) are effectively treated with tube thoracostomy.

Objectives

First objective is to compare the therapeutic effect of tube thoracostomy on COVID¹⁹ infected patients who have pneumothorax or pleural effusion to those non-COVID¹⁹ infected patients who had traumatic pneumothorax or pleural effusion treated by tube thoracostomy. Second objective is to study the morbidity associated with tube thoracostomy in COVID¹⁹ infected patients who have pneumothorax or pleural effusion.

Patients and methods

This study was conducted in Sheikh Khalifa medical city Ajman, United Arab Emirates. It is a descriptive, observational, retrospective cohort study. One hundred patients were recruited from the January 1, 2020 to the December 31, 2020. Patients were divided into two groups. First group includes fifty adult COVID ¹⁹ infected patients who had no trauma. Second group includes fifty adult COVID¹⁹ infection free patients who had trauma. Inclusion criteria for the first group: COVID ¹⁹ infected patients with an age equal to or above 18 years, of both genders, with history of pneumothorax, pleural effusion or both of them, needed insertion of thoracostomy chest tube. Inclusion criteria for the second group: Patients with an age equal to or above 18 years, of both genders, with history of traumatic pneumothorax, pleural effusion (hemothorax) or both of them, needed insertion of thoracostomy chest tube. Exclusion criteria for the first group: Children, Adult COVID¹⁹ infected patients who didn't have pneumothorax or plural effusion, adult COVID¹⁹ infected patients who had pneumothorax or plural effusion without a need for tube thoracostomy. Exclusion criteria for the second group: Adult non-COVID¹⁹ infected patients who had trauma, but didn't have pneumothorax or pleural effusion, adult non-COVID¹⁹ infected patients who had traumatic pneumothorax or pleural effusion without a need for tube thoracostomy. The collected data was revised, coded, tabulated and introduced to a PC using Statistical package for Social Science (SPSS 25). Mann Whitney Test (U test) was used to assess the statistical significance of the difference of a non-parametric variable between two study groups. Chi-Square test was used to examine the relationship between two qualitative variables. Fisher's exact test was used to examine the relationship between two qualitative variables when the expected count is less than 5 in more than 20% of cells.

Results

Most of patients in trauma group (group 2) were with the age range of 20-40-year (58.8% of patients) P value was significant (<0.001). In COVID ¹⁹ infected patients' group (group 1) the age range was 40-60 year (50%of patients). P Value (<0.001) was significant too. Male was the dominant gender in group 2 (96.1% of patients were male), while in group1 (78% of patients were male), P Value was significant (0.007). No co-morbidities (diabetes, hypertension, ischemic heart disease, Asthma and dyslipidemia) were detected in group 2 (0.0%). Co-morbidity were detected in 76% of patients in group 1, P Value was significant (<0.001). Hemothorax occurred in 37.3% of patients in group 2, and no cases of hemothorax was detected in group 1. P Value was significant (<0.001). Complications of chest tube insertion took place in group 2 as follows; tube malposition in 13.7% of patients, tube blockade in 3.9% of patients. The percentage in group 1 was as follows tube malposition in 16% of patients, tube blockade in 18%. The difference between the two was not significant for tube malposition (P value 0.748) and significant for tube blockade (P value 0.023). Subcutaneous emphysema occurred in 15.7% of patients in group 2 and in 15.7% of patients in group 1. The difference was not significant (P value was 0.118). Acquired bronchopleural fistula occurred 2.0% of group 1 cases. No cases of this fistula were documented in group 2. Number of chest tubes needed to be inserted in group 2 patients was as follows (one chest tube in: 74.5% of patients, two chest tubes in: 23.5% of patients. Three chest tubes or more in 2% of patients). While in group1 patients' number of chest tubes needed to be inserted was (one in 56% of patients, two in 30% of patients. Three or more in 14% of patients). The difference was significant only in those who required insertion of three chest tubes or more (P value was 0.028). The median duration needed to keep a chest tube was 3 days in group 2, and 7 days in group 1. The difference between the two was significant (P value was 0.000). Death was the fate of 3.9% of patients in group 2 and in 64% of patients in group 1. The difference was significant (P value was< 0.001).

Conclusion

Therapeutic effect of tube thoracostomy in treating Adult COVID¹⁹ patients who had pneumothorax or pleural effusion is less than that used in treating trauma non-COVID¹⁹ patients who had pneumothorax or plural effusion. Morbidity and mortality related to tube thoracostomy applied to treat pneumothorax or pleural effusion in adult COVID¹⁹ patients is more than that in trauma non COVID ¹⁹ patients.

Epidemiological and Clinical Characteristics of Adults with Coronavirus Disease 2019 Complicated with Pneumothorax

Background

The major brunt of coronavirus disease-2019 (COVID-2019) is borne by the lungs. The major cause of morbidity and mortality in COVID-19 patients is a compromise of the respiratory system. Pneumothorax is noted as an insignificant proportion of patients suffering from COVID-19, but it jeopardizes the clinical recovery significantly. We, in the case series of 10 patients, will be summarizing the epidemiological, demographic, and clinical characteristics of COVID-19 patients who also developed pneumothorax.

Patients and methods

All the confirmed cases of COVID-19 pneumonia diagnosed between May 1, 2020 and August 30, 2020, admitted at our center meeting the inclusion criteria and whose clinical course was complicated by pneumothorax were made part of our study. Their clinical records were studied, and epidemiological, demographic, and clinical data of these patients were collected and compiled in this case series.

Results

All the patients in our study required ICU care, and 60% received non-invasive mechanical ventilation, while 40% of the patients progressed to intubation and invasive mechanical ventilation. A total of 70% of the patients in our study had a successful outcome, while 30% succumbed to the disease and expired.

Conclusion

Epidemiological, demographic, and clinical characteristics of COVID-19 patients complicated with pneumothorax were evaluated. Our study showed that pneumothorax also developed in some patients who had not received mechanical ventilation, indicating that pneumothorax could be a secondary complication of SARS-CoV-2 infection. Our study also emphasizes the fact that even the majority of patients whose clinical course was complicated by pneumothorax had a successful outcome emphasizing the need for timely and adequate intervention in such cases.

How to cite this article

Singh NK. Epidemiological and Clinical Characteristics of Adults with Coronavirus Disease 2019 Complicated with Pneumothorax. Indian J Crit Care Med 2022;26(7):833-835.

Management of spontaneous pneumothorax in patients with COVID-19

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pneumonia may cause cystic features of lung parenchyma which can resolve or progress to larger blebs. Pneumothorax was more likely in patients with neutrophilia, severe lung injury and a prolonged clinical course. The timely diagnosis and management will reduce COVID-19-associated morbidity and mortality.

METHODS

We present 11 cases of spontaneous pneumothorax managed with chest tube thoracostomy or high-dose oxygen therapy. Isolated spontaneous pneumothorax was detected in all cases.

RESULTS

Eight cases were male and 3 cases were female. There were bilateral ground-glass opacities or pulmonary infiltrates in the parenchyma of the 10 cases. We detected neutrophilia, lymphopaenia and increased C-reactive protein, Ferritin, lactate dehydrogenase, D-Dimer, interleukin-6 levels in almost all cases. Chest tube thoracostomy was sufficient to treat pneumothorax in our 9 of case. In 2 cases, pneumothorax healed with high-dose oxygen therapy. Favipiravir and antibiotic treatment were given to different 10 patients. In our institution, all patients with COVID-19 infection were placed on prophylactic or therapeutic anticoagulation, unless contraindicated. The treatments of patients diagnosed with secondary spontaneous pneumothorax during the pandemic period and those diagnosed with secondary spontaneous pneumothorax in the previous 3 years were compared with the durations of tube thoracostomy performed in both groups.

CONCLUSIONS

The increased number of cases of pneumothorax suggests that pneumothorax may be a complication of COVID-19 infection. During medical treatment of COVID-19, pneumothorax may be the only reason for hospitalization. Although tube thoracostomy is a sufficient treatment option in most cases, clinicians should be aware of the difficulties that may arise in diagnosis and treatment.

The Role of Surgery in Patients with COVID-19-Related Thoracic Complications

Objective

Patients with several thoracic complications induced by SARS-CoV-2 infection may benefit from surgery, but its role in this condition is largely unknown, and many surgeons’ advice against any surgical referrals. Our aim is to investigate the efficacy and safety of surgery in COVID-19 patients with thoracic complications requiring surgery.

Methods

We designed a multicenter observational study, involving nine thoracic surgery departments, evaluating patients who developed thoracic complications in hospital, surgically managed from March 1, 2020, to May 31, 2021. An overall 30-day mortality was obtained by using the Kaplan–Meier method. Multivariable Cox regression model and logistic models were applied to identify the variables associated with mortality and postoperative complications.

Results

Among 83 patients, 33 (40%) underwent surgery for complicated pneumothorax, 17 (20.5%) for pleural empyema, 13 (15.5%) for hemothorax, 8 (9.5%) for hemoptysis, 5 patients (6%) for lung abscess, 4 (5%) for infected pneumatoceles, and 3 (3.5%) for other causes. Within 30 days of surgery, 60 patients (72%) survived. At multivariable analysis, age (HR 1.05 [95% CI, 1.01, 1.09], p = 0.022), pulmonary hypertension (HR 3.98 [95% CI, 1.09, 14.5], p = 0.036), renal failure (HR 2.91 [95% CI, 1.19, 7.10], p-value 0.019), thoracotomy (HR 4.90 [95% CI, 1.84, 13.1], p-value 0.001) and infective affections (HR 0.17 [95% CI, 0.05, 0.58], p-value 0.004) were found to be independent prognostic risk factors for 30-day mortality. Age (OR 1.05 [95% CI, 1.01, 1.10], p = 0.023) and thoracotomy (OR 3.85 [95% CI, 1.35, 12.0] p = 0.014) became significant predictors for 30-day morbidity.

Conclusion

Surgical management of COVID-19-related thoracic complications is affected by high mortality and morbidity rates, but a 72% survival rate still seems to be satisfactory with a rescue intent. Younger patients without pulmonary hypertension, without renal insufficiency and undergoing surgery for infectious complications appear to have a better prognosis.

Incidence, clinical associations and outcomes of intrathoracic complications with and without ARDS in COVID-19 pneumonia

PURPOSE

To determine the incidence and clinical predictors of intrathoracic complications in COVID-19 patients, and the association with outcomes.

METHODS

In this retrospective cross-sectional study, we included 976 patients (age 61 ± 17 years, 62% male) who tested positive for SARS-CoV-2 between March 3-April 4, 2020 and underwent chest imaging. 3836 radiographs from 976 patients and 105 CTs from 88 patients were reviewed for intrathoracic complications, including pneumothorax, pneumomediastinum, pneumopericardium, lobar collapse, pleural effusion, and pneumatocele formation.

RESULTS

There was a high rate of intrathoracic complications (197/976, 20%). Pleural effusion was the most common complication (168/976, 17%). Pneumothorax (30/976, 3%) and pneumatoceles (9/88, 10%) were also frequent. History of hypertension and high initial CXR severity score were independent risk factors for complications. Patients with any intrathoracic complication during admission had an over 11-fold risk of ICU admission (adjusted odds ratio [aOR] 11.2, p < 0.0001) and intubation (aOR 12.4, p < 0.0001), over 50% reduction in successful extubation (aOR 0.49, p = 0.02) and longer length of stay (median 13 versus 5 days, p < 0.0001). There was no difference in overall survival between patients with and without any complication (log-rank p = 0.94).

CONCLUSION

In COVID-19 patients who underwent chest imaging, 1 in 5 patients have an intrathoracic complication, which are associated with higher level of care and prolonged hospital stay. Hypertension history and high CXR severity score confer an increased risk of complication.

SUMMARY

Intrathoracic complications in COVID-19 are common and are predictive of ICU admission, need for intubation, less successful extubation, and longer length of stay but are not predictive of mortality.

Clinical Profile of Patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection Developing Pulmonary Barotrauma on Mechanical Ventilation

Background

There is limited information on clinical profile and outcomes of patients on mechanical ventilation (MV) who developed pulmonary barotrauma (PBT) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Patients and methods

In a retrospective observational study, all SARS-CoV-2 pneumonia patients admitted from March 28, 2020, to August 31, 2020, at Sir HN Reliance Foundation Hospital and Research Center and Seven Hills Hospital (Reliance Facility), Mumbai, India, of 18 years and above on MV and developed PBT, were included.

Results

A total of 14 SARS-CoV-2 patients of 45 on MV (31.0%) developed PBT of 1,029 hospitalized. All patients were male and divided as per admission into PaO₂/FiO₂ (P/F) ≤100 (median 80) and P/F >100 (median 222) group. Pneumothorax developed in seven and six cases of P/F ≤100 and P/F >100 groups, respectively. Three patients in each group developed subcutaneous emphysema, while four developed pneumomediastinum in P/F >100 group. Twelve patients (7, P/F ≤100, and 5, P/F >100) were on invasive, while two (P/F >100) were on noninvasive MV. The mean P/F on the day of PBT was reduced by 27.5 and 65.3%, while peak inspiratory pressure was elevated with a median of 36 and 28 cm H₂O in P/F ≤100 and P/F >100 groups, respectively. The median highest tidal volume (420 mL), positive-end expiratory pressure (8 vs 6 cm H₂O) on the day of PBT, and length of hospital stay (11 vs 25 days) did not differ between two groups. Survival was 28.6% (4/14).

Conclusion

SARS-CoV-2 patients requiring MV with PBT had poor outcomes. Clinicians should be vigilant about the diagnosis of PBT.

How to cite this article

Kargirwar KV, Rathod D, Kumar V, Patel M, Shah M, Choudhury H, et al. Clinical Profile of Patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection Developing Pulmonary Barotrauma on Mechanical Ventilation. Indian J Crit Care Med 2022;26(5):613–618.

Combined treatment with endobronchial Watanabe spigot and N-butyl-2-cyanoacrylate for refractory pneumothorax in COVID-19

Coronavirus disease 2019 (COVID-19) causes pneumothorax or mediastinal emphysema in approximately 1% of patients. According to the British Thoracic Society guidelines, the next treatment option for patients with persistent pneumothorax despite chest drainage is pleurodesis or surgery. In fact, there are reports of autologous blood pleurodesis or surgery for the treatment of pneumothorax caused by COVID-19. However, elderly patients or patients in poor general condition may not be able to tolerate surgical invasion. In this report, we present two patients who did not respond to chest drainage or pleurodesis and who were not suitable for surgery because of their poor general condition. These patients were successfully treated with an endobronchial Watanabe spigot and N-butyl-2-cyanoacrylate. This method may be an option for the treatment of refractory pneumothorax in COVID-19.

Bilateral Spontaneous Pneumothorax in a COVID-19 and HIV-Positive Patient: A Case Report

This case report describes a 60 year-old Black-American male with a past medical history of human immunodeficiency virus (HIV) infection and hyperthyroidism, who suffered a bilateral spontaneous pneumothorax (SP) in the setting of coronavirus disease 2019 (COVID-19) pneumonia. SP is a well-established complication in HIV-positive patients and only recently has been associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. While HIV and COVID-19 infections have been independently linked with increased risk of SP development, it is unknown if both infections interact in a synergistic fashion to exacerbate SP risk. According to the Centers for Disease Control and Prevention (CDC), patients living with HIV have a higher risk of developing severe COVID-19 infection and the mechanism remains to be elucidated. To the best of our knowledge, this is the first report of a HIV-positive patient, who in the setting of SARS-CoV-2 infection, developed bilateral apical spontaneous pneumothorax and was later found to have a left lower lobe tension pneumothorax. This case highlights the importance of considering SP on the differential diagnosis when HIV-positive patients suddenly develop respiratory distress in the setting of SARS-CoV-2 infection.

Post COVID-19 pulmonary complications; a single center experience

INTRODUCTION

Although the rate and severity of complications after coronavirus 2019 disease (COVID-19) resolution is currently unknown, evidence regarding their presence is increasing in the literature. This study presents a series of cases with post COVID-19 short-term pulmonary complications.

METHODS

This is a single center retrospective case series study. The demographic and clinical data were collected from the center's electronic records. All the included cases were confirmed COVID-19 patients who had pulmonary complications even after their recovery.

RESULTS

Nineteen COVID-19 patients were involved in this study. Fourteen of them were male (73.7%) and only 5 (26.3%) cases were female, with a mean age of 52.05 years (26-77). All of the patients developed severe COVID-19 and were admitted to intensive care unit (ICU). The average infection duration was 13.5 days (10-21). The most common complaints after recovery from COVID-19 were shortness of breath, fever, and hemoptysis. Computed tomography scan showed different pulmonary abnormalities between the cases. Different surgical procedures were performed for the patients according to their conditions, such as decortications, lobectomy, and bullectomy. More than half of the patients (n = 10) recovered and were discharged from hospital without complications, five patients were admitted to the ICU, 3 cases developed mucormycosis, and one case passed away.

CONCLUSION

Following the resolution of COVID-19, patients may experience severe pulmonary complications that may last for months and can affect quality of life, ICU admission, or even death.

Expanding spontaneous pneumothorax in COVID-19 pneumonia: Case report and review of literature

Coronavirus disease 2019 has presented itself with a variety of clinical signs and symptoms. One of these has been the accordance of spontaneous pneumothorax which in instances has caused rapid deterioration of patients. Furthermore pneumothorax may happen secondary to intubation and the resulting complications. Not enough is discussed regarding cases with COVID-19 related pneumothorax and proper management of these patients. The present article reports an elderly patient with spontaneous pneumothorax secondary to COVID-19 and reviews the existing literature.

Full medical treatment of COVID-19 associated large pneumothorax - A case report

A 52-year-old man was re-admitted two weeks after recovering from severe COVD-19 following a 3-days history of cough and worsening shortness of breath. The chest radiograph showed a large right-sided pneumothorax. The first attempt at drainage, performed through a large bored tube, failed. Due to the large dimension of the pneumothorax, and the lung condition (extensive consolidation and diffuse bullous dystrophies), the only thoracic surgical approach prospected was a pneumonectomy. Willing to preserve the lung, the pulmonology team attempted a multi-phase medical-oriented strategy based on medical thoracoscopy. Therefore, the patient underwent 5 chest tube insertions, 2 talc pleurodesis, and an intrapleural blood patch. Air leakage resolution was progressively achieved, and the patient became asymptomatic.             We strongly encourage a medical thoracoscopic approach for the patient presenting with recurrent pneumothorax in order to ensure complete lung re-expansion and preserve lung parenchyma.

Endobronchial valve positioning for alveolar-pleural fistula following ICU management complicating COVID-19 pneumonia

Background

The main clinical consequences of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection are pneumonia and respiratory failure even requiring mechanical ventilation. In this context, the lung parenchyma is highly prone to ventilator-related injury, with pneumothorax and persistent air leak as the most serious adverse events. So far, endobronchial valve (EBV) positioning has proved efficacious in treating air leaks with a high success rate.

Case presentation

We report, for the first time, two cases of patients affected by SARS-CoV-2-related pneumonia complicated with bacterial super-infection, experiencing pneumothorax and persistent air leaks after invasive mechanical ventilation. Despite the severity of respiratory failure both patients underwent rigid interventional bronchoscopy and were successfully treated through EBV positioning.

Conclusions

Persistent air leaks may result from lung tissue damage due to a complex interaction between inflammation and ventilator-related injury (VILI), especially in the advanced stages of ARDS. EBV positioning seems to be a feasible and effective minimally invasive therapeutic option for treating this subset of patients.

Clinical Course of Mechanically Ventilated COVID-19 Patients With Pneumothoraces

Introduction Pneumothoraces in mechanically ventilated patients with COVID-19 indicate severe lung damage from inflammatory injury and barotrauma. These patients have a high mortality rate, and additional factors may further alter their clinical course. Methods We conducted a retrospective review of patients admitted to 11 public hospitals in New York City between March 6 and April 9, 2020, diagnosed with COVID-19. We identified 39 patients who developed pneumothoraces immediately after intubation or after a period of time on mechanical ventilation. Our study population was divided into various groups using demographic and clinical characteristics. Statistical analyses were conducted using SPSS software (IBM Inc., Armonk, USA) and paired t-tests to compare clinical outcomes between the various groups. P values < 0.05 were considered statistically significant. Results Our population was comprised of 28 male (72%) and 11 female patients; 36 out of 39 patients (92.3%) died with a median time of 10 days from admission to death and a median time of 2 days from pneumothorax to death. The remaining three were discharged home or to another facility. Pneumothoraces developed immediately after intubation in 18 patients and after a period of time on mechanical ventilation in 21 patients. Factors associated with a worse clinical course included age greater than 65 years (time from admission to pneumothorax 4.81 vs 8.35 days; p = 0.011) and presence of one or more comorbidities (time from admission to intubation 2.3 days vs 4.8 days; p = 0.041). Other factors that may worsen clinical course include previous smoking (time from admission to pneumothorax 4.4 vs 8.54 days; p = 0.074) and use of positive end-expiratory pressure (PEEP) greater than 15 cm H₂O (time from intubation to pneumothorax 3.89 vs 6.42 days; p = 0.14). Conclusions Based on the findings in our retrospective review, COVID-19 patients who develop pneumothoraces on mechanical ventilation have a mortality rate in excess of 90%. Older patients and those with comorbidities have a more fulminant clinical course.

SARS-CoV-2 with concurrent coccidioidomycosis complicated by refractory pneumothorax in a Hispanic male: A case report and literature review

BACKGROUND

The incidence of secondary coinfections particularly fungal infections among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not well described. Little is known of the complications that could be encountered in such conditions.

CASE SUMMARY

A 50-year-old Hispanic male who was a prior smoker presented with shortness of breath. He was diagnosed with SARS-CoV-2. He improved and was discharged with home oxygen. A month later, he presented with sudden onset cough and shortness of breath. Chest X-ray showed development of right-sided tension pneumothorax, right pleural effusion and an air-filled cystic structure. Computed tomography thorax showed findings suggestive of pulmonary coccidioidomycosis. Coccidioides antigen was positive, and fluconazole was initiated. For pneumothorax, a pigtail catheter was placed. The pigtail chest tube was later switched to water seal, unfortunately, the pneumothorax re-expanded. Another attempt to transition chest tube to water seal was unsuccessful. Pigtail chest tube was then swapped to 32-Fr chest tube and chemical pleurodesis was performed. This was later transitioned successfully to water seal and finally removed. He was discharged on a four-week oral course of fluconazole 400 mg and was to follow up closely as an outpatient for continued monitoring.

CONCLUSION

Pneumothorax is associated with a worse prognosis, especially with comorbidities such as diabetes, immunosuppression and malignancy. Suspicion for concomitant fungal infection in such patients should be high and would necessitate further investigation.

Colon perforation as a complication of COVID-19: a case report

Background

Coagulopathy induced by COVID-19 has received much attention. Arterial and venous thrombosis of multiple organs due to COVID-19-related coagulopathy is associated with a poor outcome.

Case presentation

A 67-year-female was transferred to our hospital in need of intensive care for severe COVID-19 pneumonia. On day 7 after admission, despite the treatments, her respiratory and hemodynamic status deteriorated. Computed tomography revealed massive ascites and free air as well as wall defects of the transverse colon. An emergency laparotomy was undertaken in the intensive-care unit, and 17 cm of the transverse colon was resected. Histopathological findings revealed two perforation sites of 25 and 7 mm in diameter, necrosis of the intestinal mucosa around the perforation sites, and the microcirculatory thrombosis in the mesentery vessels which was suspected of having been induced by COVID-19-related coagulopathy.

Conclusions

The case highlights the risk of intestinal ischemia and perforation induced by COVID-19 coagulopathy. Physicians treating COVID-19 should recognize the risk and evaluate patients carefully.

Recurrent Pneumothorax in an Adult Male With Bilateral COVID-19 Pneumonia

Pneumothorax is defined as the condition in which air is collected between the visceral and parietal pleura. Pneumothorax as a complication of coronavirus disease 2019 (COVID-19) infection has been reported in relatively few cases and recurrent pneumothorax is even rarer. We present a case of a 50-year-old critically ill patient who required mechanical ventilation for 55 days and developed recurrent bilateral pneumothorax. The patient initially presented with shortness of breath and cough. He was found to be COVID-19 positive on the polymerase chain reaction (PCR) test. Subsequently, his oxygen demand increased, and he ultimately needed mechanical ventilation. He developed four episodes of pneumothorax. The patient was managed in all four episodes with intercostal tube insertion. To prevent subsequent episodes, pleurodesis was performed after the fourth episode of pneumothorax.

Risk factors for severity of COVID-19 in hospital patients age 18-29 years

BACKGROUND

Since February 2020, over 2.5 million Texans have been diagnosed with COVID-19, and 20% are young adults at risk for SARS-CoV-2 exposure at work, academic, and social settings. This study investigated demographic and clinical risk factors for severe disease and readmission among young adults 18-29 years old, who were diagnosed at a hospital encounter in Houston, Texas, USA.

METHODS AND FINDINGS

A retrospective registry-based chart review was conducted investigating demographic and clinical risk factors for severe COVID-19 among patients aged 18-29 with positive SARS-CoV-2 tests within a large metropolitan healthcare system in Houston, Texas, USA. In the cohort of 1,853 young adult patients diagnosed with COVID-19 infection at a hospital encounter, including 226 pregnant women, 1,438 (78%) scored 0 on the Charlson Comorbidity Index, and 833 (45%) were obese (≥30 kg/m2). Within 30 days of their diagnostic encounter, 316 (17%) patients were diagnosed with pneumonia, 148 (8%) received other severe disease diagnoses, and 268 (14%) returned to the hospital after being discharged home. In multivariable logistic regression analyses, increasing age (adjusted odds ratio [aOR] 1.1, 95% confidence interval [CI] 1.1-1.2, p<0.001), male gender (aOR 1.8, 95% CI 1.2-2.7, p = 0.002), Hispanic ethnicity (aOR 1.9, 95% CI 1.2-3.1, p = 0.01), obesity (3.1, 95% CI 1.9-5.1, p<0.001), asthma history (aOR 2.3, 95% CI 1.3-4.0, p = 0.003), congestive heart failure (aOR 6.0, 95% CI 1.5-25.1, p = 0.01), cerebrovascular disease (aOR 4.9, 95% CI 1.7-14.7, p = 0.004), and diabetes (aOR 3.4, 95% CI 1.9-6.2, p<0.001) were predictive of severe disease diagnoses within 30 days. Non-Hispanic Black race (aOR 1.6, 95% CI 1.0-2.4, p = 0.04), obesity (aOR 1.7, 95% CI 1.0-2.9, p = 0.046), asthma history (aOR 1.7, 95% CI 1.0-2.7, p = 0.03), myocardial infarction history (aOR 6.2, 95% CI 1.7-23.3, p = 0.01), and household exposure (aOR 1.5, 95% CI 1.1-2.2, p = 0.02) were predictive of 30-day readmission.

CONCLUSIONS

This investigation demonstrated the significant risk of severe disease and readmission among young adult populations, especially marginalized communities and people with comorbidities, including obesity, asthma, cardiovascular disease, and diabetes. Health authorities must emphasize COVID-19 awareness and prevention in young adults and continue investigating risk factors for severe disease, readmission and long-term sequalae.

Pneumothorax in critically COVID-19 patients with mechanical ventilation

Coronavirus disease 2019 (COVID-19) is a public health emergency caused by SARS-CoV-2. A few studies reported pneumothorax in patients with COVID-19. Pneumothorax is associated with an increased morbidity and mortality. Hence, it should be considered during the treatment and follow-up of patients with COVID-19. Herein, we reported four cases of pneumothorax in critical COVID-19 patients hospitalized in the ICU and treated with a mechanical ventilation. All patients were diagnosed with COVID-19, type 1 respiratory failure, and acute respiratory distress syndrome. All patients developed pneumothorax during mechanical ventilation, although the ventilator settings were set to lung-protective strategy.

Case Report: Barotrauma in COVID-19 Case Series

Severe acute respiratory syndrome coronavirus 2 can cause pulmonary complications, such as increased risk of barotrauma (BT), but its prevalence and risk factors are not known. In this case series, the course of BT and its related risk factors were discussed in patients with COVID-19 who were admitted to the intensive care unit. Medical records of the patients with COVID-19 and BT and hospitalized in the intensive care unit for 5 months were extracted. The course of BT and its possible associated risk factors are descriptively presented. Among 103 patients with COVID-19 who were intubated, 13 patients (12.6%) had BT. One patient developed BT before intubation. All patients with BT were male. Half of them developed BT in the first 5 days of intubation. Eight patients (61.53%) had a positive culture for Klebsiella pneumoniae. Nine patients (69.9%) died. High positive end-expiratory pressure, coinfection with bacterial pneumonia, and history of lung disease may affect BT incidence. The treatment team should increase their upervision on the ventilator setting, especially in the first week of intubation.

Favourable outcome after a delayed complication secondary to COVID-19

A 41-year-old man was admitted to hospital with 7-day history of fever, cough and having had a positive SARS-CoV-2 PCR test. The chest radiograph (CXR) showed bilateral peripheral parenchymal infiltrates. He required 4 L/min oxygen via nasal cannula for 72 hours and was discharged after 7 days with appropriate advice. Four weeks from initial hospital admission, he presented with worsening cough, left chest pain and breathlessness. CXR showed left pneumothorax, and CT pulmonary angiogram (CTPA) scan confirmed left pneumothorax with mediastinal shift and a subpleural bulla. Intercostal chest drain was inserted with good resolution of symptoms and lung re-expansion. Follow-up CT scan 2 months later showed complete resolution of the parenchymal abnormalities. Our case demonstrates the development of pneumothorax as a delayed complication in a patient with COVID-19 who did not require ventilatory support. The case also illustrates a favourable outcome, that is, complete resolution of parenchymal destruction due to COVID-19.

Delayed recurrent spontaneous pneumothorax post-recovery from COVID-19 infection

Pneumothorax, as a consequence of coronavirus disease 2019 (COVID-19) infection, has become an established entity but the delayed occurrence of pneumothorax, after recovery from the illness, is less commonly reported. We present a case of delayed recurrent spontaneous pneumothorax, presenting 4 weeks after recovery from COVID-19 in a previously healthy middle-aged gentleman, for which uniportal video-assisted thoracoscopic surgery (VATS) pleurectomy was performed, but the cause of pneumothorax could not be ascertained. This report brings to light, the importance of continued surveillance of COVID-19 survivors, the unpredictability of the disease process, and the challenges of thoracic surgery in this unique subset of patients.

Pneumothorax in Mechanically Ventilated Patients with COVID-19 Infection

Data on patient-related factors associated with pneumothorax among critically ill patients with COVID-19 pneumonia is limited. Reports of spontaneous pneumothorax in patients with coronavirus disease 2019 (COVID-19) suggest that the COVID-19 infection could itself cause pneumothorax in addition to the ventilator-induced trauma among mechanically ventilated patients. Here, we report a case series of five mechanically ventilated patients with COVID-19 infection who developed pneumothorax. Consecutive cases of intubated patients in the intensive care unit with the diagnosis of COVID-19 pneumonia and pneumothorax were included. Data on their demographics, preexisting risk factors, laboratory workup, imaging findings, treatment, and survival were collected retrospectively between March and July 2020. Four out of five patients (4/5; 80%) had a bilateral pneumothorax, while one had a unilateral pneumothorax. Of the four patients with bilateral pneumothorax, three (3/4; 75%) had secondary bacterial pneumonia, two had pneumomediastinum and massive subcutaneous emphysema, and one of these two had an additional pneumoperitoneum. A surgical chest tube or pigtail catheter was placed for the management of pneumothorax. Three out of five patients with pneumothorax died (3/5; 60%), and all of them had bilateral involvement. The data from these cases suggest that pneumothorax is a potentially fatal complication of COVID-19 infection. Large prospective studies are needed to study the incidence of pneumothorax and its sequelae in patients with COVID-19 infection.

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

Coronavirus disease 2019 (COVID-19) causes significant morbidity and mortality for a proportion of infected patients, and our knowledge and understanding of its clinical, radiological and histopathological features are still evolving. An association between COVID-19 and pneumothorax has been described in an increasing number of case reports and series in the literature, which have largely focused on clinical and imaging features. We report the case of a patient who developed COVID-19 complicated by pneumothorax, requiring surgical intervention. We describe the histopathological features seen in the thorascopically resected bullectomy specimen—this is, to our knowledge, the first reported description of the morphological features of pneumothorax in this important clinical setting.

A successful case of extracorporeal membrane oxygenation treatment for intractable pneumothorax in a patient with COVID-19

Background

Some patients with coronavirus disease 2019 (COVID‐19) develop pneumothorax. Tube thoracotomy and bulla resection could generate aerosols and cause virus transmission; the optimal treatment strategy remains unclear.

Case Presentation

A 57‐year‐old male was transferred as a severe COVID‐19 pneumonia case. On the 16th day after admission, the patient’s respiratory condition deteriorated, and the chest X‐ray revealed the presence of severe right‐sided pneumothorax. A chest drain was immediately inserted; however, a significant air leak continued, and severe ventilator settings were required. Thus, veno‐venous extracorporeal membrane oxygenation (VV‐ECMO) treatment was initiated to allow the lungs to rest. After 10 days of lung‐protective ventilation, the patient was weaned from ECMO and the chest drain was removed on the following day with no major comorbidities.

Conclusion

The combination of ECMO with lung rest strategy could be a treatment option for intractable pneumothorax with COVID‐19 to avoid unnecessary surgical procedures and aerosol generation.

Adult cardiovascular surgery and the coronavirus disease 2019 (COVID-19) pandemic: the Italian experience

The coronavirus disease 2019 (COVID-19) pandemic has profoundly affected all health care professionals. The outbreak required a thorough reorganization of the Italian regional local health care system to preserve resources such as ventilators, beds in intensive care units and surgical and anaesthesiological staff. Levels of priority were created, together with a rigorous triage procedure for patients with COVID-19, which led to postponement of all elective procedures. Urgent cases were discussed with the local heart team and percutaneous approaches were selected as the first treatment option to reduce hospital stay. COVID-19 and COVID-19-free pathways were created, including adequate preparation of the operating room, management of anaesthesiological procedures, transportation of patients and disinfection. It was determined that patients with chronic diseases were at increased risk of adverse outcomes. Systemic inflammation, cytokine storm and hypercoagulability associated with COVID-19 increased the risk of heart failure and cardiac death. In this regard, the early use of extracorporeal membrane oxygenation could be life-saving in patients with severe forms of acute respiratory distress syndrome or refractory heart failure. The goal of this paper was to report the Italian experience during the COVID-19 pandemic in the setting of cardiovascular surgery.

Salvage Lobectomy to Treat Necrotizing SARS-CoV-2 Pneumonia Complicated by a Bronchopleural Fistula

We report a case of necrotizing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia complicated by a bronchopleural fistula and treated by decortication and salvage lobectomy. Owing to the unknown characteristics of the underlying SARS-CoV-2 infection, treatment of the abscess and bronchopleural fistula was delayed. This may have resulted in further deterioration of the patient, with ensuing multiple organ dysfunction. Complications of SARS-CoV-2 pneumonia, such as a bacterial abscess and a bronchopleural fistula, should be treated as if the patient were not infected with SARS-CoV-2.

Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study

BACKGROUND

Recent reports of patients with coronavirus disease 2019 (COVID-19) 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.

Pneumothorax in a COVID-19 Pneumonia Patient without Underlying Risk Factors

Coronavirus disease 2019 (COVID-19) has been recognized as a worldwide pandemic. However, the clinical course of COVID-19 remains poorly characterized. Although some cases of pneumothorax have been reported, they all had pulmonary complications or were managed with mechanical ventilation. We herein report a case of pneumothorax that developed even though the patient had no pulmonary underlying diseases and had never been managed with mechanical ventilation. In the present case, a lung bulla was found on chest computed tomography during treatment for COVID-19. We concluded that COVID-19 affected the formation of the lung bulla and induced the complication of pneumothorax.

COVID-19 and pneumothorax: a multicentre retrospective case series

INTRODUCTION

Pneumothorax and pneumomediastinum have both been noted to complicate cases of coronavirus disease 2019 (COVID-19) requiring hospital admission. We report the largest case series yet described of patients with both these pathologies (including nonventilated patients).

METHODS

Cases 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.

RESULTS

71 patients from 16 centres were included in the study, of whom 60 had pneumothoraces (six with pneumomediastinum in addition) and 11 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 while 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. 28-day survival was not different between the sexes (males 62.5±7.7% versus females 68.4±10.7%; p=0.619). Patients aged ≥70 years 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).

CONCLUSION

These 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 continuation of active treatment where clinically possible.

Recommendations for interventional pulmonology during COVID-19 outbreak: a consensus statement from the Portuguese Pulmonology Society

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by a novel SARS-CoV-2 pathogen. Its capacity for human-to-human transmission through respiratory droplets, coupled with a high-level of population mobility, has resulted in a rapid dissemination worldwide. Healthcare workers have been particularly exposed to the risk of infection and represent a significant proportion of COVID-19 cases in the worst affected regions of Europe. Like other open airway procedures or aerosol-generating procedures, bronchoscopy poses a significant risk of spreading contaminated droplets, and medical workers must adapt the procedures to ensure safety of both patients and staff. Several recommendation documents were published at the beginning of the pandemic, but as the situation evolves, our thoughts should not only focus on the present, but should also reflect on how we are going to deal with the presence of the virus in the community until there is a vaccine or specific treatment available. It is in this sense that this document aims to guide interventional pulmonology throughout this period, providing a set of recommendations on how to perform bronchoscopy or pleural procedures safely and efficiently.

Recurrent Pneumothorax in a Critically Ill Ventilated COVID-19 Patient

We present this case of a young woman with SARS-CoV-2 viral infection resulting in coronavirus 2019 (COVID-19) lung disease complicated by a complex hydropneumothorax, recurrent pneumothorax, and pneumatoceles. A 33-year-old woman presented to the hospital with a one-week history of cough, shortness of breath, and myalgia, with no other significant past medical history. She tested positive for COVID-19 and subsequently, her respiratory function rapidly deteriorated, necessitating endotracheal intubation and mechanical ventilation. She had severe hypoxic respiratory failure requiring a protracted period on the mechanical ventilator with different ventilation strategies and multiple cycles of prone positioning. During her proning, after two weeks on the intensive care unit, she developed tension pneumothorax that required bilateral intercostal chest drains (ICD) to stabilise her. After 24 days, she had a percutaneous tracheostomy and began her respiratory wean; however, this was limited due to the ongoing infection. Thorax CT demonstrated a left-sided pneumothorax, with bilateral pneumatoceles and a sizeable, complex hydropneumothorax. Despite the insertion of ICDs, the hydropneumothorax persisted over months and initially progressed in size on serial scans needing multiple ICDs. She was too ill for surgical interventions initially, opting for conservative management. After 60 days, she successfully underwent a video-assisted thoracoscopic surgery (VATS) for a washout and placement of further ICDs. She was successfully decannulated after 109 days on the intensive care unit and was discharged to a rehabilitation unit after 116 days of being an inpatient, with her last thorax CT showing some residual pneumatoceles but significant improvement. Late changes may mean patients recovering from the COVID-19 infection are at increased risk of pneumothoracies. Clinicians need to be alert to this, especially as bullous rupture may not present as a classical pneumothorax.

Case report of sequential bilateral spontaneous pneumothorax in a never-ventilated, lung-healthy COVID-19-patient

INTRODUCTION

Patients with COVID-19 infection and severe lung parenchyma alterations may need mechanical ventilation with subsequent pneumothorax and eventually persistent air leak in case of pre-existing lung disease.

PRESENTATION OF CASE

This report presents the case of a never-ventilated 58 years old male patient without pre-existing, underlying lung disease demonstrating severe lung parenchyma changes due to COVID-19-pneumonia. He suffered from recurrent bilateral spontaneous pneumothoraces, which were successfully treated with bilateral thoracoscopy and resections of the destroyed lung areas. Notably, he has already been under treatment with anticoagulation due to portal thrombosis 8 years ago.

DISCUSSION

Although especially know from patients under mechanical ventilation, this patient suffered from spontaneous pneumothorax without ever been ventilated. Probably due to the severe vascular inflammatory changes and focal endothelitis like also seen in other organs of COVID-19 patients, the pneumothorax may lead to a prolonged air leak, which needs surgical therapy. The patients pre-existing anticoagulation therapy may prevented him from a mere severe course.

CONCLUSION

Early surgical therapy may be considered in COVID-19 patients with persistent air leak, even if not mechanically ventilated. Simultaneously, the role of early anticoagulation needs further investigation.

Characteristics, laboratories, and prognosis of severe COVID-19 in the Tokyo metropolitan area: A retrospective case series

The impact of the COVID-19 pandemic has been immense, while the epidemiology and pathophysiology remain unclear. Despite many casualties in many countries, there have been less than 1,000 deaths in Japan as of end of June, 2020. In this study, we analyzed the cases of COVID-19 patients admitted to our institution located in the Tokyo metropolitan area where the survival rate is higher than those in other cities in the world. Medical records of COVID-19 patients that were admitted to a single Japanese tertiary university hospital in the Tokyo metropolitan area between March 10th and June 2nd, 2020 were retrospectively reviewed. The identified COVID-19 cases were subdivided into two groups (severe and mild) depending on the need for mechanical ventilation. Those in the severe group required mechanical ventilation as opposed to those in the mild group. The data were analyzed using nonparametric tests expressed by median [interquartile range (IQR)]. A total of 45 COVID-19 patients were included, consisting of 22 severe cases (Group S) and 23 mild cases (Group M). Male sex (Group S, 95.5% vs. Group M, 56.5%, p<0.01), high body mass index (Group S, 24.89 [22.44-27.15] vs. Group M, 21.43 [19.05-23.75], p<0.01), and hyperlipidemia (Group S, 36.4% vs. Group M, 0%, p<0.01) were more seen in Group S. Five (22.7%) cases in Group S underwent extracorporeal membranous oxygenation (ECMO). On admission, lymphopenia, decreased albumin, and elevated fibrinogen, lactate dehydrogenase, transaminases, creatine kinase, C-reactive protein, and procalcitonin were observed in Group S. The median ICU and hospital stay were 13.5 [10.3-22.3] days and 23.0 [16.3-30.5] days, respectively, in Group S. As of June 28th, 2020, in Group S, 19 (86.4%) patients have survived, of which 17 (77.3%) were discharged, and 2 are still in treatments. Three died of multiple organ failure. All 23 patients in Group M have recovered. Male sex, high body mass index, and hyperlipidemia can be risk factors for severe COVID-19 pneumonia, and its overall short-term survival rate was between 77.3% and 86.4% in this study.

Expectant management of pneumothorax in intubated COVID-19 positive patients: a case series

Background

There is an increasing amount of literature describing the pathogenesis of coronavirus disease 2019 (COVID-19) pneumonia and its associated complications. Historically, a small pneumothorax has been shown to be successfully treated without chest tube insertion, but this management has yet to be proven in COVID-19 pneumonia patients. In addition, pneumothorax in an intubated patient with high positive end-expiratory pressure (PEEP) provides additional uncertainty with pursuing non-operative management.

Case presentation

In this series we report four cases of patients with respiratory distress who tested positive for COVID-19 via nasopharyngeal swab and developed ventilator-induced pneumothoraces which were successfully managed with observation alone.

Conclusions

Management of patients with COVID-19 pneumonia on positive pressure ventilation who develop small stable pneumothoraces can be safely observed without chest tube insertion.

Pneumothorax in COVID-19 disease- incidence and clinical characteristics

Background

Spontaneous pneumothorax is an uncommon complication of COVID-19 viral pneumonia. The exact incidence and risk factors are still unknown. Herein we review the incidence and outcomes of pneumothorax in over 3000 patients admitted to our institution for suspected COVID-19 pneumonia.

Methods

We performed a retrospective review of COVID-19 cases admitted to our hospital. Patients who were diagnosed with a spontaneous pneumothorax were identified to calculate the incidence of this event. Their clinical characteristics were thoroughly documented. Data regarding their clinical outcomes were gathered. Each case was presented as a brief synopsis.

Results

Three thousand three hundred sixty-eight patients were admitted to our institution between March 1st, 2020 and June 8th, 2020 for suspected COVID 19 pneumonia, 902 patients were nasopharyngeal swab positive. Six cases of COVID-19 patients who developed spontaneous pneumothorax were identified (0.66%). Their baseline imaging showed diffuse bilateral ground-glass opacities and consolidations, mostly in the posterior and peripheral lung regions. 4/6 cases were associated with mechanical ventilation. All patients required placement of a chest tube. In all cases, mortality (66.6%) was not directly related to the pneumothorax.

Conclusion

Spontaneous pneumothorax is a rare complication of COVID-19 viral pneumonia and may occur in the absence of mechanical ventilation. Clinicians should be vigilant about the diagnosis and treatment of this complication.

Case Report: COVID-19-Associated Bilateral Spontaneous Pneumothorax-A Literature Review

COVID-19 is a pandemic caused by SARS-CoV-2, primarily affecting the respiratory tract. Pulmonary complications of COVID-19 may include acute respiratory distress syndrome and pulmonary embolism. Pneumothorax has been recently reported in association with COVID-19. We report a case of COVID-19 pneumonia with bilateral spontaneous pneumothorax with no known underlying lung disease or risk factors.

Recurrent pneumothorax in a COVID-19 patient: A case report

An 88-year-old woman diagnosed with COVID-19 in Brazil presented with recurrent pneumothorax. She was under mechanical ventilation for 20 days because of acute respiratory distress syndrome (ARDS). Chest x-ray revealed right lung pneumothorax, which was treated with a pigtail chest tube leading to successful lung reexpansion. After 48 hours the patient developed an ipsilateral pneumothorax and a new tube thoracostomy under conventional chest tube under suction was performed and kept in place for 14 days.

This brief report highlights that the conventional chest tube under suction procedures might be a good choice in Covid-19 patients.

Recommendations for acting in elective and urgent thoracic surgery during SARS-CoV-2 pandemic. Spanish Society of Thoracic Surgery

La expansión de la pandemia producida por el nuevo coronavirus SARS-CoV-2 ha obligado a focalizar casi toda la asistencia sanitaria en pacientes con enfermedad COVID-19, obligando a suspender la mayoría de intervenciones quirúrgicas electivas programadas. La cirugía torácica es eminentemente oncológica, por lo que resulta obligada una adecuada priorización de los pacientes para ser intervenidos lo antes posible y en condiciones de máxima seguridad. Por otra parte, la afectación pulmonar grave COVID-19 presenta complicaciones que con frecuencia requieren procedimientos quirúrgicos torácicos urgentes en un contexto nuevo. La Sociedad Española de Cirugía Torácica (SECT) ha desarrollado este documento para establecer unas recomendaciones básicas para mantener la actividad quirúrgica electiva imprescindible y para orientar a los cirujanos que deban afrontar urgencias torácicas en este nuevo y desconocido entorno.

Case Report: Pneumothorax and Pneumomediastinum as Uncommon Complications of COVID-19 Pneumonia-Literature Review

As the COVID-19 pandemic progresses, awareness of uncommon presentations of the disease increases. Such is the case with pneumothorax and pneumomediastinum. Recent evidence suggested that these can occur in the context of COVID-19 pneumonia, even in the absence of mechanical ventilation-related barotrauma. We present two patients with COVID-19 pneumonia complicated by pneumomediastinum. The first patient was a 55-year-old woman who developed COVID-19 pneumonia. Her clinical course was complicated by pneumothorax and pneumomediastinum, and, unfortunately, she died 2 days following the admission. The second patient was a 31-year-old man who developed a small pneumomediastinum and was managed conservatively. He had a spontaneous resolution of the pneumomediastinum and was discharged 19 days later. None of our patients required invasive or noninvasive positive pressure ventilation. We performed a literature review of COVID-19 pneumonia cases that developed pneumothorax, pneumomediastinum, or both. The analysis showed that the latter had high mortality (60%). Thus, it is necessary to pay attention to these complications as early identification and management can reduce the associated morbidity and mortality.