Pneumothorax in COVID-19 disease- incidence and clinical characteristics

Association of dietary intake with pneumothorax: A Mendelian randomization study

Background

An association between dietary habits and lung disease has been demonstrated in previous studies. Employing Mendelian randomization, we aimed to explore how different dietary intakes relate to pneumothorax, shedding light on the interplay among gut flora, the lung-gut axis, and pneumothorax.

Methods

Employing both two-sample and multi-sample Mendelian randomization (MR) analyses, we investigated 24 dietary intake variables to establish a strong association with pneumothorax. Causal inferences were drawn using the inverse variance weighted (IVW) method. To fortify our findings, we employed a diverse array of methodologies, including Weighted Median Estimator (WME), Weighted Mode, Simple Mode, Mendelian Randomization Pleiotropy Residual Sum and Outlier (MR-PRESSO), MR-Egger regression, and LASSO.

Results

Our analysis identified genetic variants reliably predicting dietary intakes, meeting stringent criteria (p < 5 × 10-8) and demonstrating independence (r2 < 0.001). Causal-effect estimates derived from the IVW model unveiled a statistically significant association, indicating a causal correlation between pneumothorax and three dietary intakes. Specifically, heightened consumption of fresh fruit (OR = 0.196, 95%CI: 0.063-0.606, p = 0.004) and dried fruit (OR = 0.323, 95%CI: 0.114-0.911, p = 0.032) correlated with reduced pneumothorax risk, while increased processed meat intake (OR = 2.705, 95%CI: 1.026-7.128, p = 0.044) showed a positive correlation.

Conclusion

In summary, our MR analysis yields robust evidence supporting a causal correlation between dietary elements and pneumothorax. This study significantly advances our comprehension of pneumothorax risk factors, protective agents, and the intricate mechanisms of the lung-gut axis.

Comparison of the risk of pneumothorax in COVID-19 and seasonal influenza

Limited evidence exists regarding the link between coronavirus disease 2019 (COVID-19) and pneumothorax. Therefore, we aimed to evaluate the occurrence rate of pneumothorax in hospitalized patients with COVID-19 and compare the risk of pneumothorax between patients with COVID-19 and influenza. This retrospective cohort study used patient data from the National Health Insurance Service of South Korea. Patients diagnosed with COVID-19 (December 2019 to December 2021) and influenza (January 2019 to December 2021) who required hospitalization and respiratory support were included. We identified 46,460 patients with COVID-19 and 6,117 with influenza. The occurrence rate of pneumothorax was 0.74% in patients with COVID-19. In an inverse probability of treatment weighting matched cohort, the Cox proportional hazards regression model showed that COVID-19 was not associated with an increased risk of pneumothorax compared to influenza (hazard ratio, 1.22; 95% confidence interval, 0.75-1.99). However, the risk of pneumothorax associated with COVID-19 compared to influenza was significantly higher in patients without chronic lung disease than in those with (P for heterogeneity = 0.037). In conclusion, COVID-19, compared with influenza, is not associated with an increased risk of pneumothorax; however, it is associated with an increased risk in patients without chronic lung disease.

Impact of COVID-19 infection among patients hospitalized for conventional pacemaker implantation: Analysis of the Nationwide Inpatient Sample (NIS) 2020

Introduction

The cardiac pacemaker is indicated for treating various types of bradyarrhythmia, providing lifelong cardiovascular benefits. Recent data showed that COVID-19 has impacted procedure numbers and led to adverse long-term outcomes in patients with cardiac pacemakers. However, the impact of COVID-19 infection on the in-hospital outcome of patients undergoing conventional pacemaker implantation remains unclear.

Method

Patients aged above 18 years who were hospitalized for conventional pacemaker implantation in the Nationwide In-patient Sample (NIS) 2020 were identified using relevant ICD-10 CM and PCS codes. Multivariable logistic and linear regression models were used to analyze pre-specified outcomes, with the primary outcome being in-patient mortality and secondary outcomes including system-based and procedure-related complications.

Results

Of 108 020 patients hospitalized for conventional pacemaker implantation, 0.71% (765 out of 108 020) had a concurrent diagnosis of COVID-19 infection. Individuals with COVID-19 infection exhibited a lower mean age (73.7 years vs. 75.9 years, p = .027) and a lower female proportion (39.87% vs. 47.60%, p = .062) than those without COVID-19. In the multivariable logistic and linear regression models, adjusted for patient and hospital factors, COVID-19 infection was associated with higher in-hospital mortality (aOR 4.67; 95% CI 2.02 to 10.27, p < .001), extended length of stay (5.23 days vs. 1.04 days, p < .001), and linked with various in-hospital complications, including sepsis, acute respiratory failure, post-procedural pneumothorax, and venous thromboembolism.

Conclusion

Our study suggests that COVID-19 infection is attributed to higher in-hospital mortality, extended hospital stays, and increased adverse in-hospital outcomes in patients undergoing conventional pacemaker implantation.

Impact of pneumothorax on mortality, morbidity, and hospital resource utilization in COVID-19 patients: a propensity matched analysis of nationwide inpatient sample database

BACKGROUND

Spontaneous pneumothorax (PTX) is more prevalent among COVID-19 patients than other critically ill patients, but studies on this are limited. This study compared clinical characteristics and in-hospital outcomes among COVID-19 patients with concomitant PTX to provide insight into how PTX affects health care utilization and complications, which informs clinical decisions and healthcare resource allocation.

METHODS

The 2020 Nationwide Inpatient Sample was used analyze patient demographics and outcomes, including age, race, sex, insurance status, median income, length of hospital stay, mortality rate, hospitalization costs, comorbidities, mechanical ventilation, and vasopressor support. Propensity score matching was employed for additional analysis.

RESULTS

Among 1,572,815 COVID-19 patients, 1.41% had PTX. These patients incurred significantly higher hospitalization costs ($435,508 vs. $96,668, p < 0.001) and longer stays (23.6 days vs. 8.6 days, p < 0.001). In-hospital mortality was substantially elevated for PTX patients (65.8% vs. 14.4%, p < 0.001), with an adjusted odds ratio of 14.3 (95% CI 12.7-16.2). Additionally, these patients were more likely to require vasopressors (16.6% vs. 3.3%), mechanical circulatory support (3.5% vs. 0.3%), hemodialysis (16.6% vs. 5.6%), invasive mechanical ventilation (76.9% vs. 15.1%), non-invasive mechanical ventilation (19.1% vs. 5.8%), tracheostomy (13.3% vs. 1.1%), and chest tube placement (59.8% vs. 0.8%).

CONCLUSIONS

Our findings highlight the severe impact of PTX on COVID-19 patients, characterized by higher mortality, more complications, and increased resource utilization. Also, being Hispanic, male, or obese increased the risk of developing concomitant PTX with COVID-19.

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.

Prevalence and patient risk factors for pneumothorax in COVID-19 and in influenza pneumonia: a nationwide comparative analysis

Background

Pneumothorax is a rare but deadly complication in patients who require mechanical ventilation. As with any condition associated with acute respiratory distress syndrome (ARDS), coronavirus disease 2019 (COVID-19) is known to be associated with pneumothorax. However, in the literature, comparative data on the risk factors for pneumothorax in COVID-19 and other diseases like influenza are limited. The aim of this study is to determine the prevalence and risk factors for pneumothorax in hospitalized COVID-19 patients and compare them with influenza pneumonia patients.

Methods

This study is a retrospective analysis of the National Inpatient Sample (NIS) 2020 database cohort. Univariate and multivariate logistic regression were used to identify the prevalence and risk factors for pneumothorax in COVID-19 patients and compared with the risk of pneumothorax in influenza patients.

Results

The NIS 2020 database includes 1,608,980 hospitalizations of COVID-19 patients, of which 22,545 [95% confidence interval (CI): 21,491-23,598] (1.4%) developed pneumothorax. On multivariate analysis, factors associated with pneumothorax in COVID-19 included patient age of 41-64 years; male sex; Hispanics, Native Americans, and other races; hospitals with large-bed size; privately owned hospitals; urban teaching hospitals; hospitals in the southern United States (US); stroke; malnutrition; chronic obstructive pulmonary disease (COPD); bronchiectasis; pulmonary fibrosis; liver disease; non-invasive and invasive ventilation; and extracorporeal membrane oxygenation (ECMO). Of 184,980 influenza patients, 1,630 (95% CI: 1,448-1,811) (0.88%) developed pneumothorax. The prevalence of pneumothorax was higher (1.4%) in COVID-19 patients compared to patients with influenza pneumonia (0.88%).

Conclusions

COVID-19 patients who develop pneumothorax have a poor prognosis. Several risk factors for the development of pneumothorax were identified. Patients with these risk factors should be prioritized in applying evidence-based guidelines to prevent pneumothorax.

Outcomes of Tube Thoracostomies in COVID-19 Patients: A Retrospective Cohort Study in the University of the Philippines - Philippine General Hospital COVID-19 Referral Center

Objective

To describe the treatment outcomes of patients who underwent tube thoracostomy for pleural complications in patients with COVID-19 and determine the association between patient profile and treatment outcomes.

Methods

A single-institution retrospective review of patients who underwent tube thoracostomy for complications of COVID-19 infection in the University of the Philippines - Philippine General Hospital (UP-PGH) from March 30, 2020, to March 31, 2021, was performed. These patients' demographic and clinical profiles were evaluated using median, frequencies, and percentages. The association between patient profile, and mortality and reintervention rates was assessed using univariable Cox proportional hazards regression analysis.

Results

Thirty-four (34) of 3,397 patients (1.00%) admitted for COVID-19 pneumonia underwent tube thoracostomy. Of these, 34, 47.06% were male, 52.94% were female, the median age was 51.5 years old, 85.29% had comorbid conditions, and 29.41% had a previous or ongoing tuberculous infection. The most common indication for tube thoracostomy was pleural effusion (61.76%), followed by pneumothorax (29.41%), and pneumo-hydrothorax (8.82%). The mortality rate was 38.24%, and the reintervention rate was 14.71%. Intubated patients had 14.84 times higher mortality hazards than those on room air. For every unit increase in procalcitonin levels, the mortality hazards were increased by 1.06 times.

Conclusion

An increasing level of oxygen support on admission and a level of procalcitonin were directly related to mortality risk in COVID-19 patients who underwent tube thoracostomy for pleural complications. There is insufficient evidence to conclude that patient-related, COVID-19 pneumonia-related, and procedure-related factors included in this study were significantly associated with reintervention risk.

Clinical characteristics of pneumothorax and pneumomediastinum in mechanical ventilated patients with coronavirus disease 2019: a case series

BACKGROUND

Pneumothorax (PTX) and pneumomediastinum (PM) have been reported as potential complications in patients with coronavirus disease 2019 (COVID-19); however, their risk factors and etiology remain unknown. Herein, we investigated the clinical characteristics of mechanically ventilated patients with COVID-19 with PTX or PM.

METHODS

We examined patients with severe COVID-19 requiring mechanical ventilation who were admitted to the intensive care unit of a tertiary-level emergency medical center in Tokyo, Japan between April 1, 2020. and October 31, 2021. We collected and analyzed the clinical characteristics of the patients who presented with either PTX or PM during mechanical ventilation.

RESULTS

During the study period, a total of 165 patients required mechanical ventilation, and 15 patients with PTX/PM during mechanical ventilation were selected. Three patients with obvious causes were excluded, and the remaining 12 patients were analyzed (7.3%). The mortality rate in these patients was as high as 50%, demonstrating the difficulty of treatment in the presence of PTX/PM. PTX/PM occurred 14.5 days after intubation. A peak pressure of > 30 cmH2O was only apparent in one patient, suggesting that high positive pressure ventilation may be less involved than mentioned in the literature. In addition, the inspiratory effort was not strong in our group of patients. (P0.1 was 2.1 cm H2O [1.0-3.8]).

CONCLUSION

Various factors are associated with the development of PTX/PM in patients on mechanical ventilation for COVID-19. We did not find a strong correlation between PTM/PM and barotrauma or strong inspiratory efforts, which have been identified as potential causes in previous studies.

The gut microbe pair of Oribacterium sp. GMB0313 and Ruminococcus sp. GMB0270 confers complete protection against SARS-CoV-2 infection by activating CD8+ T cell-mediated immunity

Despite the potential protective role of the gut microbiome against COVID-19, specific microbes conferring resistance to COVID-19 have not yet been identified. In this work, we aimed to identify and validate gut microbes at the species level that provide protection against SARS-CoV-2 infection. To identify gut microbes conferring protection against COVID-19, we conducted a fecal microbiota transplantation (FMT) from an individual with no history of COVID-19 infection or immunization into a lethal COVID-19 hamster model. FMT from this COVID-19-resistant donor resulted in significant phenotypic changes related to COVID-19 sensitivity in the hamsters. Metagenomic analysis revealed distinct differences in the gut microbiome composition among the hamster groups, leading to the identification of two previously unknown bacterial species: Oribacterium sp. GMB0313 and Ruminococcus sp. GMB0270, both associated with COVID-19 resistance. Subsequently, we conducted a proof-of-concept confirmation animal experiment adhering to Koch's postulates. Oral administration of this gut microbe pair, Oribacterium sp. GMB0313 and Ruminococcus sp. GMB0270, to the hamsters provided complete protection against SARS-CoV-2 infection through the activation of CD8+ T cell mediated immunity. The prophylactic efficacy of the gut microbe pair against SARS-CoV-2 infection was comparable to, or even superior to, current mRNA vaccines. This strong prophylactic efficacy suggests that the gut microbe pair could be developed as a host-directed universal vaccine for all betacoronaviruses, including potential future emerging viruses.

A Case of Bilateral Pneumothorax With COVID-19 Infection

Bilateral spontaneous pneumothorax is a serious complication of coronavirus disease 2019 (COVID-19). The incidence of any spontaneous pneumothorax in patients with the aforementioned viral infection when hospitalized is about 1%. Treatment can involve management such as oxygen support, tube thoracostomy, pleurodesis, or even invasive surgery. The associated mortality with this complication is about 33% to 52%. We present a case of bilateral pneumothorax in a patient diagnosed with COVID-19 without any history of smoking or underlying lung disease. Careful vigilance and close monitoring of this serious complication are mandatory in inpatients.

Severe SARS-CoV-2 Pneumonia and Pneumomediastinum/Pneumothorax: A Prospective Observational Study in an Intermediate Respiratory Care Unit

INTRODUCTION

The occurrence of pneumomediastinum (PM) and/or pneumothorax (PTX) in patients with severe pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was evaluated.

METHODS

This was a prospective observational study conducted in patients admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital in Madrid (Spain) between December 14, 2020 and September 28, 2021. All patients had a diagnosis of severe SARS-CoV-2 pneumonia and required noninvasive respiratory support (NIRS): high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). The incidences of PM and/or PTX, overall and by NIRS, and their impact on the probabilities of invasive mechanical ventilation (IMV) and death were studied.

RESULTS

A total of 1306 patients were included. 4.3% (56/1306) developed PM/PTX, 3.8% (50/1306) PM, 1.6% (21/1306) PTX, and 1.1% (15/1306) PM + PTX. 16.1% (9/56) of patients with PM/PTX had HFNC alone, while 83.9% (47/56) had HFNC + CPAP/BiPAP. In comparison, 41.7% (521/1250) of patients without PM and PTX had HFNC alone (odds ratio [OR] 0.27; 95% confidence interval [95% CI] 0.13-0.55; p < .001), while 58.3% (729/1250) had HFNC + CPAP/BiPAP (OR 3.73; 95% CI 1.81-7.68; p < .001). The probability of needing IMV among patients with PM/PTX was 67.9% (36/53) (OR 7.46; 95% CI 4.12-13.50; p < .001), while it was 22.1% (262/1185) among patients without PM and PTX. Mortality among patients with PM/PTX was 33.9% (19/56) (OR 4.39; 95% CI 2.45-7.85; p < .001), while it was 10.5% (131/1250) among patients without PM and PTX.

CONCLUSIONS

In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia requiring NIRS, incidences of PM/PTX, PM, PTX, and PM + PTX were observed to be 4.3%, 3.8%, 1.6%, and 1.1%, respectively. Most patients with PM/PTX had HFNC + CPAP/BiPAP as the NIRS device, much more frequently than patients without PM and PTX. The probabilities of IMV and death among patients with PM/PTX were 64.3% and 33.9%, respectively, higher than those observed in patients without PM and PTX, which were 21.0% and 10.5%, respectively.

Ventilatory associated barotrauma in COVID-19 patients: A multicenter observational case control study (COVI-MIX-study)

BACKGROUND

The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication.

METHODS

This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death.

RESULTS

We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001).

CONCLUSIONS

C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality.

TRIAL REGISTRATION

this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021).

Lung ultrasound-guided PEEP titration in COVID-19 patients treated with CPAP

OBJECTIVES

An increasing number of COVID-19 patients were treated with continuous positive airways pressure (CPAP). To evaluate the clinical effects of personalized positive end-expiratory pressure (PEEP) compared to standard fixed PEEP in COVID-19 patients requiring CPAP.

METHODS

This is a single center, prospective, randomized clinical study. Sixty-three COVID-19 patients with hypoxemic respiratory failure and bilateral pneumonia were randomized in two Groups: Group A received CPAP with fixed PEEP of 10 cm H2O, Group B performed the "PEEP trial", that consists in the evaluation of best PEEP defined as the PEEP value that precedes the echographic appearance of "lung pulse" determining a PaO2/FiO2 increase. Primary outcome was composite in-hospital mortality + intubation, secondary outcome was the percentage increase of PaO2/FiO2. As safety indicator, the incidence of pneumothorax was collected.

RESULTS

Thirty-two patients were enrolled in Group A and 31 in Group B. The two groups were comparable for clinical characteristics and laboratory parameters. The primary outcome occurred in 36 (57.1 %) patients: 23 (71.8 %) in Group A and 13 (41.9 %) in Group B (p<0.01). Mortality was higher in Group A (53.1 vs. 19.3 %, p<0.01), while intubation rate was comparable between groups. Group B showed a higher PaO2/FiO2 increase than Group A (34.9 vs. 13.1 %, p<0.01). Five cases of pneumothorax were reported in Group A, none in Group B.

CONCLUSIONS

Lung ultrasound-guided PEEP trial is associated with lower mortality in COVID-19 patients treated with CPAP. Identifying the best PEEP is useful to increase oxygenation and reduce the incidence of complications.

Pneumothorax in Acute Neurologically Ill COVID-19 Positive Patients: A Brief Report

Background

Pneumothorax is reported as a complication of coronavirus disease-2019 (COVID-19). The present report describes the incidence, clinical characteristics, and outcomes of pneumothorax in acute neurologically ill COVID-19 positive patients admitted to the COVID-19 neuro-intensive care unit (CNICU).

Methods

In this retrospective study, pneumothorax was identified by reviewing chest radiographs of acute neurologically ill patients with and without associated COVID-19 admitted to the CNICU and non-COVID-19 NICU, respectively, from July to November 2020. The clinico-epidemiological characteristics of acute neurologically ill COVID-19 positive patients with pneumothorax are described.

Results

The incidence of pneumothorax was 17% (8/47) in acute neurologically ill COVID-19 positive patients in the CNICU and 14.6% (6/41) in patients who received mechanical ventilation (MV). In contrast, the incidence of pneumothorax in acute neurologically ill non-COVID-19 patients admitted to the NICU was 3.7% (7/188) and 0.69% (1/143) in patients receiving MV.

Conclusion

In our study, the incidence of pneumothorax was higher in patients with concomitant neurological and COVID-19 diseases than in acute neurologically ill non-COVID-19 patients managed during the same period in the ICUs.

Incidence of Air Leak Syndrome in Pediatric Patients With SARS-COV-2 Pneumonia and Respiratory Failure: A Single-Center Retrospective Study

Air leak syndrome (ALS) is defined as the extrusion of air from an aerated compartment into an unaerated compartment with associated symptoms of respiratory distress. This syndrome can occur as a consequence of trauma, iatrogenic causes, or spontaneously. Retrospective investigations conducted in the adult population have demonstrated an elevated risk of spontaneous ALS development in patients with coronavirus disease 2019 (COVID-19) pneumonia, along with its correlation with mortality. However, no studies have yet explored this phenomenon within the pediatric population. In light of this knowledge gap, we conducted a retrospective chart review comprising 128 pediatric patients ranging in age from one month to 18 years. The primary objective was to assess the incidence of ALS in two distinct groups: patients diagnosed with COVID-19 pneumonia and those with non-COVID-19 viral pneumonia. The groups were compared using Fisher's exact test for sex, the presence of ALS, the requirement of extracorporeal membrane oxygenation (ECMO), and death. The modified Wald method was used to calculate the 95% confidence interval for the mortality rate in patients with COVID-19 pneumonia in the presence of ALS. Our findings revealed a higher prevalence of ALS in patients with COVID-19 pneumonia compared to the non-COVID-19 viral pneumonia group, with a statistically significant P-value of 0.02 and an odds ratio (OR) of 6.72. In terms of mortality rates, there was a statistically significant difference between the two groups (P = 0.025, OR = 1.083). In addition, in patients with ALS in the presence of COVID-19 pneumonia, the mortality rate was 37.5%. However, the requirement of ECMO was not statistically significant (P = 0.16, OR = 1.04). These results suggest that patients with COVID-19 pneumonia have an increased mortality rate and a heightened risk of developing ALS compared to individuals with other viral pneumonias. Furthermore, the presence of ALS was associated with a high mortality rate in COVID-19 pneumonia patients. However, it is crucial to note that obtaining a larger patient sample and involving multiple institutions would be necessary to obtain more consistent and robust data.

COVID-19-Related Pleural Diseases

Coronavirus disease 2019 (COVID-19)-related pleural diseases are now well recognized. Since the beginning of the pandemic, increasing cases of pleural diseases including pneumothorax, pneumomediastinum, and pleural effusion with severe COVID-19 infection have attracted the attention of physicians and are not incidental or due to barotrauma. The complicated course of COVID-19 illness highlights the complex pathophysiological underpinnings of pleural complications. The management of patients with pneumothorax and pneumomediastinum is challenging as the majority require assisted ventilation; physicians therefore appear to have a low threshold to intervene. Conversely, pleural effusion cases, although sharing some similar patient characteristics with pneumothorax and pneumomediastinum, are in general managed more conservatively. The evidence suggests that patients with COVID-19-related pleural diseases, either due to air leak or effusion, have more severe disease with a worse prognosis. This implies that prompt recognition of these complications and targeted management are key to improve outcomes.

A Pictorial Essay Describing the CT Imaging Features of COVID-19 Cases throughout the Pandemic with a Special Focus on Lung Manifestations and Extrapulmonary Vascular Abdominal Complications

With the Omicron wave, SARS-CoV-2 infections improved, with less lung involvement and few cases of severe manifestations. In this pictorial review, there is a summary of the pathogenesis with particular focus on the interaction of the immune system and gut and lung axis in both pulmonary and extrapulmonary manifestations of COVID-19 and the computed tomography (CT) imaging features of COVID-19 pneumonia from the beginning of the pandemic, describing the typical features of COVID-19 pneumonia following the Delta variant and the atypical features appearing during the Omicron wave. There is also an outline of the typical features of COVID-19 pneumonia in cases of breakthrough infection, including secondary lung complications such as acute respiratory distress disease (ARDS), pneumomediastinum, pneumothorax, and lung pulmonary thromboembolism, which were more frequent during the first waves of the pandemic. Finally, there is a description of vascular extrapulmonary complications, including both ischemic and hemorrhagic abdominal complications.

Pneumomediastinum in patients with COVID-19 undergoing CT pulmonary angiography: a retrospective cohort study

BACKGROUND

Various complications have been reported in patients with COVID-19 including pneumomediastinum.

METHODS

The primary objective of the study was to determine the incidence of pneumomediastinum in COVID-19 positive patients who underwent CT pulmonary angiography (CTPA). The secondary objectives were to analyse if the incidence of pneumomediastinum changed between March and May 2020 (peak of the first wave in the UK) and January 2021 (peak of the second wave in the UK) and to determine the mortality rate in patients with pneumomediastinum. We undertook an observational, retrospective, single-centre, cohort study of patients with COVID-19 admitted to Northwick Park Hospital.

RESULTS

74 patients in the first wave and 220 patients in the second wave met the study criteria. Two patients during the first wave and eleven patients during the second wave developed pneumomediastinum.

CONCLUSIONS

The incidence of pneumomediastinum changed from 2.7% during the first wave to 5% during the second wave and this change was not statistically significant (p value 0.4057). The difference in mortality rates of patients with pneumomediastinum in both waves of COVID-19 (69.23%) versus patients without pneumomediastinum in both waves of COVID-19 (25.62%) was statistically significant (p value 0.0005). Many patients with pneumomediastinum were ventilated, which could be a confounding factor. When controlling for ventilation, there was no statistically significant difference in the mortality rates of ventilated patients with pneumomediastinum (81.81%) versus ventilated patients without pneumomediastinum (59.30%) (p value 0.14).

Bilateral spontaneous pneumothorax as a late complication of COVID-19, a clinical case report

Key Clinical Message

Bilateral spontaneous pneumothorax and sudden dyspnea can occur as late complication in patients with COVID-19 even without any history of mechanical ventilation usage.

Abstract

Bilateral spontaneous pneumothorax can occur as a late complication in patients with COVID-19, even without any history of mechanical ventilation. Here, we present a patient with mild COVID-19 pneumonia with a left massive pneumothorax in the third week of hospitalization and the addition of a right pneumothorax.

COVID-19 Bullous Lung Disease Superinfection by Raoultella planticola

Bullous lung lesions from coronavirus disease 2019 (COVID-19) pneumonia, causing pneumothorax, are a rare complication, affecting up to 1% of infected patients. Raoultella planticola is an aerobic, gram-negative bacteria known to cause opportunistic infection. We present a rare case of spontaneous pneumothorax from rupture of lung bulla as a late sequela from COVID-19 pneumonia and superinfection of the bulla by R. planticola. Although superinfection of bullous lesions is known, this is the first reported case of R. planticola pneumonia in a patient with COVID-19 lung bullae. COVID-19 patients are at heightened risk for bullous lung lesions and superinfection by opportunistic organisms; thus, they should be followed up closely.

Predictors of Pneumothorax in People With COVID-19 Pneumonia: A Multicenter Retrospective Investigation

This multicenter retrospective investigation aimed to identify predictors of pneumothorax (PTX), pneumomediastinum (PM), and subcutaneous emphysema (SE) in patients with COVID-19 pneumonia admitted to the ICU. A total of 256 patients were included, with 128 in the case group and 128 in the control group. The study sample consisted of predominantly male patients with a mean age of around 53 years and a high prevalence of comorbidities. Significant predictors of PTX, PM, and SE included the presence of coronary artery disease, non-rebreather mask usage, high-flow oxygen therapy, mechanical ventilation, pressor usage, inpatient dialysis, steroid usage, sedative usage, narcotic usage, paralytic usage, elevated C-reactive protein levels, increased lung infiltration, the presence of PM and SE, mode of ventilation, duration of various respiratory support interventions, and severity of illness as indicated by APACHE and SOFA scores. These findings have important implications for the clinical management of patients with COVID-19 pneumonia, as they may help identify and closely monitor at-risk individuals, allowing for timely intervention and potentially improving clinical outcomes. Future research should focus on validating these predictors in larger cohorts and investigating the underlying mechanisms to develop targeted preventive and therapeutic strategies.

Spontaneous pneumothorax and COVID-19: Precipitants to a complex HIV-AIDS diagnosis

A 48-year-old male presented with spontaneous pneumothorax requiring chest tube placement in the setting of COVID-19 infection. CT chest revealed bilateral ground-glass opacities and multiple, large, gas-filled, cavitary lesions in the lungs bilaterally. These imaging findings led to an initial HIV diagnosis with the patient presenting at a CD4+ count of <32 cells/µL. He was found to additionally have infections with Mycobacterium kansasii, cytomegalovirus, Pneumocystis jirovecii, and Candida albicans. After developing worsening hypoxic respiratory failure, he developed additional pneumothoraces bilaterally, requiring repeated chest tube placement. He was treated with antimicrobial therapy for his underlying infections and subsequently started on combined antiretroviral therapy.

Stenotrophomonas maltophilia pneumonia in critical COVID-19 patients

Stenotrophomonas maltophilia, an environmental aerobic non-fermentative Gram-negative bacilli, has gained attention in many nosocomial outbreaks. COVID-19 patients in intensive care unit have extended hospital stay and are severely immunosuppressed. This study aimed to determine the prevalence and risk factors of S. maltophilia pneumonia in critical COVID-19 patients. A total of 123 COVID-19 patients in ICU admitted between March 2020 and March 2021 were identified from the authors' institutional database and assessed for nosocomial pneumonia. Demographic data and factors predisposing to S. maltophilia pneumonia were collected and analyzed. The mean age was 66 ± 13 years and 74% were males. Median APACHE and SOFA scores were 13 (IQR = 8-19) and 4 (3-6), respectively. The Median NEWS2 score was 6 (Q1 = 5; Q3 = 8). The Median ICU stay was 12 (Q1 = 7; Q3 = 22) days. S. maltophilia was found in 16.3% of pneumonia patients, leading to a lengthier hospital stay (34 vs. 20 days; p < 0.001). Risk factors for S. maltophilia pneumonia included previous treatment with meropenem (p < 0.01), thrombopenia (p = 0.034), endotracheal intubation (p < 0.001), foley catheter (p = 0.009) and central venous catheter insertion (p = 0.016). S. maltophilia nosocomial pneumonia is frequent in critical COVID-19 patients. Many significant risk factors should be addressed to reduce its prevalence and negative impact on outcomes.

Pneumothorax in Critically Ill COVID-19 Patients in the Indian Subcontinent

Background and aims

To explore the incidence and risk factors, as well as mortality, in critically ill COVID-19 patients who developed pneumothorax (PTX) and/or pneumomediastinum (PNM).

Methods

A retrospective cohort study was undertaken to analyse data of all patients with moderate to severe COVID-19 disease who were either RTPCR positive or had a clinico-radiological diagnosis. The exposure group consisted of COVID-19 patients who presented with PTX/PNM, whereas the non-exposure group consisted of patients who did not develop PTX and/or PNM during the stay.

Results

Incidence of PTX/PNM was observed to be 1.9% among critically ill COVID-19 patients. 94.4% (17/18) of patients in the PTX group received positive pressure ventilation (PPV); the majority of these patients were on non-invasive ventilation when they developed PTX/PNM; only one patient was receiving conventional oxygen therapy. COVID-19 patients who developed PTX/PNM had 2.7 times higher mortality. A mortality rate of 72.2% was observed in COVID-19 patients who developed PTX/PNM.

Conclusion

Development of PTX/PNM in critically ill COVID-19 patients is associated with more severe disease involvement, and institution of PPV is an additional risk factor. Significantly high mortality was observed following PTX/PNM in critically ill COVID-19 patients and is an independent marker of poor prognosis in COVID-19 disease.

THE EFFECT OF COVID-19 VACCINES ON PNEUMOTHORAX IN GERIATRIC PATIENTS HOSPİTALIZED IN INTENSIVE CARE UNIT DUE TO COVID-19

In our study, we examined the effect of COVID-19 vaccination on the incidence of pneumothorax in intensive care patients over age 65. COVID-19 intensive care patients that presented to our department between April 2020 and May 2021 during the COVID-19 pandemic were evaluated retrospectively. Patients were divided into two main groups, i.e., before and after the vaccination period. Patients were evaluated retrospectively for the following parameters: gender, age, side of pneumothorax, mortality, discharge, comorbidity, and additional pleural complications. The total number of patients was 87, i.e., 66 patients before vaccination and 21 patients after vaccination. When patients in the pre- and post-vaccination period were compared, there was a significant difference in the incidence of pneumothorax between the two groups (p<0.05). Pneumothorax was less common after vaccination. When patients with pneumothorax and tube thoracostomy were evaluated according to pre- and post-vaccination mortality, mortality was significantly higher (89%) in the pre-vaccination period (p<0.05). We consider that COVID-19 vaccines used in patients aged over 65 reduced the incidence of pleural complications, especially pneumothorax. We think that mortality due to pneumothorax in patients over 65 years of age was lower during the vaccination period. In addition, we think that bilateral pneumothorax was more common in the non-vaccinated period. As a result, we think that life-threatening pneumothorax and similar complications could be reduced by increasing the number of vaccines made in the COVID-19 pandemic and spreading it around the world.

Two in one: Overlapping CT findings of COVID-19 and underlying lung diseases

Coronavirus disease 2019 (COVID-19) is associated with pneumonia and has various pulmonary manifestations on computed tomography (CT). Although COVID-19 pneumonia is usually seen as bilateral predominantly peripheral ground-glass opacities with or without consolidation, it can present with atypical radiological findings and resemble the imaging findings of other lung diseases. Diagnosis of COVID-19 pneumonia is much more challenging for both clinicians and radiologists in the presence of pre-existing lung disease. The imaging features of COVID-19 and underlying lung disease can overlap and obscure the findings of each other. Knowledge of the radiological findings of both diseases and possible complications, correct diagnosis, and multidisciplinary consensus play key roles in the appropriate management of diseases. In this pictorial review, the chest CT findings are presented of patients with underlying lung diseases and overlapping COVID-19 pneumonia and the various reasons for radiological lung abnormalities in these patients are discussed.

Automatic deep learning-based consolidation/collapse classification in lung ultrasound images for COVID-19 induced pneumonia

Our automated deep learning-based approach identifies consolidation/collapse in LUS images to aid in the identification of late stages of COVID-19 induced pneumonia, where consolidation/collapse is one of the possible associated pathologies. A common challenge in training such models is that annotating each frame of an ultrasound video requires high labelling effort. This effort in practice becomes prohibitive for large ultrasound datasets. To understand the impact of various degrees of labelling precision, we compare labelling strategies to train fully supervised models (frame-based method, higher labelling effort) and inaccurately supervised models (video-based methods, lower labelling effort), both of which yield binary predictions for LUS videos on a frame-by-frame level. We moreover introduce a novel sampled quaternary method which randomly samples only 10% of the LUS video frames and subsequently assigns (ordinal) categorical labels to all frames in the video based on the fraction of positively annotated samples. This method outperformed the inaccurately supervised video-based method and more surprisingly, the supervised frame-based approach with respect to metrics such as precision-recall area under curve (PR-AUC) and F1 score, despite being a form of inaccurate learning. We argue that our video-based method is more robust with respect to label noise and mitigates overfitting in a manner similar to label smoothing. The algorithm was trained using a ten-fold cross validation, which resulted in a PR-AUC score of 73% and an accuracy of 89%. While the efficacy of our classifier using the sampled quaternary method significantly lowers the labelling effort, it must be verified on a larger consolidation/collapse dataset, our proposed classifier using the sampled quaternary video-based method is clinically comparable with trained experts' performance.

Diagnostic and Therapeutic Characteristics in Patients with Pneumotorax Associated with COVID-19 versus Non-COVID-19 Pneumotorax

Introduction: Pneumothorax is a condition that usually occurs in thin, young people, especially in smokers. It is an unusual complication of COVID-19 disease that can be associated with worse results. This disease can occur without pre-existing lung disease or without mechanical ventilation. Materials and Methods: We present a monocentric comparative retrospective study of diagnostic and treatment analysis of two groups of patients diagnosed with COVID-19 and non-COVID-19 pneumothorax. All patients included in this study underwent surgery in a thoracic surgery department. The study was conducted over a period of 18 months. It included 34 patients with COVID-19 pneumothorax and 42 patients with non-COVID-19 pneumothorax. Results: The clinical symptoms were more intense in patients with COVID-19 pneumothorax. We found that the patients with COVID-19 had significantly more respiratory comorbidities. Diagnostic procedures include chest CT exam for both groups. Laboratory findings showed that increasing values for the analyzed data were consistent with the deterioration of the general condition and the appearance of pneumothorax in the COVID-19 group. The therapeutic attitude regarding the non-COVID-19 group was to eliminate the air from the pleural cavity and surgical approach to the lesion that determined the occurrence of pneumothorax. The group of patients with COVID-19 pneumothorax received systemic treatment, and only minimal pleurotomy was performed. The surgical approach did not alter patients’ survival. Conclusions: Careful monitoring of the patient’s clinic and laboratory tests evaluating the degradation of the lung parenchyma, correlated with the imaging examination (chest CT) is mandatory and reduces COVID-19 complications. Early imaging examination starts an effective diagnosis and treatment management. In severe COVID-19 pneumothorax cases, the pneumothorax did not influence the evolution of COVID-19 disease. When we found that the general condition worsened with the rapid progression of dyspnea and the deterioration of the general condition, and we found that it represented the progression or recurrence of pneumothorax.

Evaluation of Patients Who Developed Pneumothorax Due to COVID-19

Background: Although SARS-CoV-2 infection often affects the lungs, pneumothorax is extremely rare. The aim of this study was to analyze the characteristics of patients who were hospitalized due to COVID-19 and who developed pneumothorax (PNX) and to analyze their risk factors. Methods: Patients who developed PNX, among the patients who were followed up in the hospital due to COVID-19 between 1 April 2020 and 1 April 2022, were included in the study. The mean and standard deviation values of the descriptive statistics were obtained from patient data. The entire application was carried out using IBM SPSS 26 (IBM Corp., Armonk, NY, USA). p values < 0.05 were considered statistically significant. Results: We observed that advanced age and male gender increase the risk of COVID-19 patientsdeveloping PNX, but smoking, sepsis, and being followed-up with mechanical ventilation do not increase this risk. In addition, we observed that the presence of an additional disease increases the mortality rate. Conclusion: We show that advanced age and male gender increase the risk for PNX, which is a rare complication of COVID-19, and that comorbidity is associated with mortality in these patients.

Development of bullous lung disease with pneumothorax following SARS-CoV-2 infection

Cystic lung formation secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was described during coronavirus disease pandemic, but with relatively low prevalence. A rare yet under-recognized complication is that these cystic areas may progress to bullae, cavities and pneumothorax. We reported two cases of ruptured bullae with pneumothorax following SARS-CoV-2 infection. Two patients were discharged following SARS-CoV-2 pneumonia, which did not require invasive mechanical ventilation (IMV). However, both patients presented again a month later with shortness of breath. Repeated computed tomography (CT) thorax showed development of bullous lung disease and pneumothorax. The first patient underwent surgical intervention whilst the second patient was treated conservatively. Development of bullous lung disease following SARS-CoV-2 infection is rare but may be associated with serious morbidity. Patients whose general condition permits should be offered surgical intervention whilst conservative management is reserved for non-surgical candidates.

Hydropneumothorax Post COVID-19 Infection

A 32-year-old male presented to the hospital with chief complaints of fever, cough, and breathlessness for the past 4 days and was found to be positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). On arrival at the hospital, the patient required supplemental oxygen. In addition, injection enoxaparin 80 mg subcutaneous twice a day and injection methylprednisolone 40 mg IV twice a day were administered for 10 days. Following this, the patient reported symptomatic improvement and was shifted to the ward with O2 @ 2 L/min through nasal prongs. However, the same evening he complained of right-sided pleuritic chest pain and developed worsening hypoxemia. CT scan of the thorax confirmed the presence of hydropneumothorax with a mediastinal shift to the left side. An intercostal drain (ICD) was placed after shifting him to the intensive care unit (ICU); pleural fluid sent for analysis confirmed the presence of a secondary bacterial infection for which he was treated with appropriate parenteral antibiotics.

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.

Secondary Pneumothorax Induced by a Bronchopleural Fistula in a Patient With COVID-19 Pneumonia

COVID-19 is a multi-system disease caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). One of the main highlights of the disease is the development of pneumonia complicated by adult respiratory distress syndrome. While spontaneous pneumothorax has been reported in some patients with COVID-19, bronchopleural fistula has seldom been reported as the primary cause in these cases. We describe the rare case of a young patient who developed a pneumothorax complicating COVID-19 and was found to have a bronchopleural fistula and empyema secondary to Staphylococcus aureus superinfection.

COVID-19-Associated Tension Pneumothorax in Mechanically Ventilated Patients: A Case Series

Severe acute respiratory syndrome management secondary to coronavirus (SARS-CoV-2) has been overwhelming for healthcare systems. Patients with SARS-CoV-2 infection can present with symptoms ranging from a mild flu-like illness to acute respiratory distress syndrome (ARDS). Patients who develop coronavirus disease 2019 (COVID-19) infection and present with hypoxic respiratory failure requiring mechanical ventilation typically follow ARDS physiology. Many of them develop complications including pneumothorax, pneumomediastinum, and pneumopericardium. In this case series, we present multiple instances where patients with severe COVID-19 infections developed tension pneumothoraces during their hospital course.

Characteristics and Factors Associated With Mortality in Patients With Coronavirus Disease 2019 and Pneumothorax

Objective

To describe the incidence, clinical characteristics, and factors associated with mortality in patients hospitalized for coronavirus disease 2019 (COVID-19) in whom pneumothorax developed.

Patients and Methods

This study was a retrospective analysis conducted using a large administrative database of adult patients hospitalized for COVID-19 in the United States from February 1, 2020, to June 10, 2021. We characterized the clinical features of patients in whom pneumothorax developed and the factors associated with mortality and stratified pneumothorax by the timing of the initiation of invasive mechanical ventilation (IMV) and by the time of hospital admission (early versus late).

Results

A total of 811,065 adult patients had a positive test result for severe acute respiratory syndrome coronavirus 2, of whom 103,858 (12.8%) were hospitalized. Pneumothorax occurred in 1915 patients (0.24% overall and 1.84% among hospitalized patients). Over time, the use of steroids and remdesivir increased, whereas the use of IMV, pneumothorax rates, and mortality decreased. The clinical characteristics associated with pneumothorax were male sex; the receipt of IMV; and treatment with steroids, remdesivir, or convalescent plasma. Most patients with pneumothorax received IMV, but pneumothorax developed before the initiation of IMV and/or early during hospitalization in majority. Multivariable analysis revealed that pneumothorax increased the risk of death (adjusted hazard ratio [aHR], 1.15; 95% CI, 1.06-1.24). In patients who did not receive IMV, pneumothorax led to nearly twice the mortality (aHR, 1.99; 95% CI, 1.56-2.54). Increased mortality was also noted when pneumothorax occurred before IMV (aHR, 1.37; 95% CI, 1.11-1.69) and within 7 days of hospital admission (aHR, 1.60; 95% CI, 1.29-1.98).

Conclusion

The overall incidence of pneumothorax in patients hospitalized for COVID-19 was low. Pneumothorax is an independent risk factor for death.

A case report, bilateral spontaneous pneumothorax as a late complication for SARS CoV-2 infection

The beta-coronavirus discovered in Wuhan in 2019 (COVID-19) provokes a series of affections from mild symptoms to life-threatening complications. There is evidence that associates the disease to spontaneous pneumothorax, however, the mechanism is unknown. The patient was a 45-year-old male with previous pneumonia due to COVID-19 who was attended the emergency department, where chest radiography was taken, confirming the diagnosis of right pneumothorax. However, the patient developed a new episode of pleuritic pain three days later, and a new radiograph showed left pneumothorax requiring a new chest tube. The simple tomography shows intraparenchymal bullae in the apical region of both lungs. The patient was kept under observation, and when improving, both endopleural chest drains were removed, and the patient was discharged. Spontaneous bilateral pneumothorax is a rare and potentially life-threatening complication. Identifying pulmonary bullae in patients with COVID-19 could be an early sign for these patients to develop spontaneous pneumothorax.

Reduced survival in patients requiring chest tubes with COVID-19 acute respiratory distress syndrome

Background

Numerous complications requiring tube thoracostomy have been reported among critically ill patients with COVID-19; however, there has been a lack of evidence regarding outcomes following chest tube placement.

Methods

We developed a retrospective observational cohort of all patients admitted to an intensive care unit (ICU) with confirmed COVID-19 to describe the incidence of tube thoracostomy and factors associated with mortality following chest tube placement.

Results

In total, 1705 patients with laboratory confirmed COVID-19 patients were admitted to our ICUs from March 7, 2020, to March 1, 2021, with 69 out of 1705 patients (4.0%) receiving 130 chest tubes. Of these, 89 out of 130 (68%) chest tubes were indicated for pneumothorax. Patients receiving tube thoracostomy were much less likely to be alive 90 days post-ICU admission (52% vs 69%; P < .01), and had longer ICU (30 vs 5 days; P < .01) and hospital (37 vs 10 days; P < .01) lengths of stay compared with those without tube thoracostomy. Patients who received tube thoracostomy and survived at least 90 days post-ICU admission had shorter times to first chest tube insertion (8.5 vs 17.0 days; P = .01) and a nonsignificantly higher static compliance (20.0 vs 17.5 mL/cm H₂O; P = .052) at the time of chest tube placement than those who had expired. Logistic regression analysis demonstrated an association between time to first chest tube and decreased survival when adjusted for covariates.

Conclusions

Requiring a chest tube in COVID-19 is a negative prognostic end point. Delayed development of chest tube requirement was associated with a decreased survival and could reflect a poor healing phenotype.

Simultaneous Spontaneous Bilateral Tension Pneumothorax Post COVID-19 Infection: A Case Study

Simultaneous bilateral spontaneous pneumothorax is a rare life-threatening condition that can cause severe respiratory distress, hypoxemia, and death. Spontaneous pneumothorax has been reported as an uncommon but severe complication in patients recovering from COVID-19 pneumonia. Even fewer cases of spontaneous bilateral tension pneumothorax have been reported as a result of infection.

We present a patient with spontaneous bilateral tension pneumothorax 18 days after COVID-19 infection. The patient’s symptoms began with a substernal tearing sensation and pain radiating to the back with dyspnea. Physical exam was significant for oxygen saturation of 75% on room air, tachycardia, and diminished breath sounds bilaterally. Imaging confirmed large bilateral pneumothoraces, and chest tubes were inserted emergently to restore lung volume.

Pneumothorax is predominantly observed in those with severe infection but has been seen with mild symptoms as well. The development of pneumothorax is thought to result from diffuse lung injury that occurred from a cytokine storm during COVID infection. We speculate that our patient developed bulla as a result of infection, and the bulla spontaneously ruptured, inducing the bilateral collapse of the lungs. The mortality of such an event remains unknown, but without proper intervention, mortality increases significantly in these patients.

As we continue to learn about the multitude of sequelae that can result from COVID-19 infection, pneumothorax should be considered in patients with a history of COVID pneumonia that presents with acute onset of dyspnea and chest pain. It is important to quickly recognize such cases as these patients have a narrow time frame for intervention, especially in the event of bilateral tension pneumothorax. Therefore, pneumothorax should be adequately assessed on initial examination, with the possibility of bilateral pneumothoraces in mind, to minimize morbidity and mortality.

Early short course of neuromuscular blocking agents in patients with COVID-19 ARDS: a propensity score analysis

BACKGROUND

The role of neuromuscular blocking agents (NMBAs) in coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) is not fully elucidated. Therefore, we aimed to investigate in COVID-19 patients with moderate-to-severe ARDS the impact of early use of NMBAs on 90-day mortality, through propensity score (PS) matching analysis.

METHODS

We analyzed a convenience sample of patients with COVID-19 and moderate-to-severe ARDS, admitted to 244 intensive care units within the COVID-19 Critical Care Consortium, from February 1, 2020, through October 31, 2021. Patients undergoing at least 2 days and up to 3 consecutive days of NMBAs (NMBA treatment), within 48 h from commencement of IMV were compared with subjects who did not receive NMBAs or only upon commencement of IMV (control). The primary objective in the PS-matched cohort was comparison between groups in 90-day in-hospital mortality, assessed through Cox proportional hazard modeling. Secondary objectives were comparisons in the numbers of ventilator-free days (VFD) between day 1 and day 28 and between day 1 and 90 through competing risk regression.

RESULTS

Data from 1953 patients were included. After propensity score matching, 210 cases from each group were well matched. In the PS-matched cohort, mean (± SD) age was 60.3 ± 13.2 years and 296 (70.5%) were male and the most common comorbidities were hypertension (56.9%), obesity (41.1%), and diabetes (30.0%). The unadjusted hazard ratio (HR) for death at 90 days in the NMBA treatment vs control group was 1.12 (95% CI 0.79, 1.59, p = 0.534). After adjustment for smoking habit and critical therapeutic covariates, the HR was 1.07 (95% CI 0.72, 1.61, p = 0.729). At 28 days, VFD were 16 (IQR 0-25) and 25 (IQR 7-26) in the NMBA treatment and control groups, respectively (sub-hazard ratio 0.82, 95% CI 0.67, 1.00, p = 0.055). At 90 days, VFD were 77 (IQR 0-87) and 87 (IQR 0-88) (sub-hazard ratio 0.86 (95% CI 0.69, 1.07; p = 0.177).

CONCLUSIONS

In patients with COVID-19 and moderate-to-severe ARDS, short course of NMBA treatment, applied early, did not significantly improve 90-day mortality and VFD. In the absence of definitive data from clinical trials, NMBAs should be indicated cautiously in this setting.

Deep learning of chest X-rays can predict mechanical ventilation outcome in ICU-admitted COVID-19 patients

The COVID-19 pandemic repeatedly overwhelms healthcare systems capacity and forced the development and implementation of triage guidelines in ICU for scarce resources (e.g. mechanical ventilation). These guidelines were often based on known risk factors for COVID-19. It is proposed that image data, specifically bedside computed X-ray (CXR), provide additional predictive information on mortality following mechanical ventilation that can be incorporated in the guidelines. Deep transfer learning was used to extract convolutional features from a systematically collected, multi-institutional dataset of COVID-19 ICU patients. A model predicting outcome of mechanical ventilation (remission or mortality) was trained on the extracted features and compared to a model based on known, aggregated risk factors. The model reached a 0.702 area under the curve (95% CI 0.707-0.694) at predicting mechanical ventilation outcome from pre-intubation CXRs, higher than the risk factor model. Combining imaging data and risk factors increased model performance to 0.743 AUC (95% CI 0.746-0.732). Additionally, a post-hoc analysis showed an increase performance on high-quality than low-quality CXRs, suggesting that using only high-quality images would result in an even stronger model.

Air leaks in COVID-19 pneumonia

The novel coronavirus infection 2019 (COVID-19), which was first identified in Wuhan, China in December 2019 and caused a pandemic, is mostly survived with mild symptoms, while invasive and non-invasive mechanical ventilation support is required in some patients. Pneumothorax, pneumomediastinum, and subcutaneous emphysema may develop in COVID-19 patients. In this study, cases of pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients who were followed in the intensive care unit with the diagnosis of COVID-19 were evaluated. In conclusion, although rare, these complications can be fatal and increase the severity of the disease, which already has a high mortality rate in the intensive care unit. Early detection and management of these complications can reduce morbidity and mortality.

Neumotórax espontáneo primario no asociado a ventilación mecánica invasiva en pacientes con neumonía por COVID-19. Presentación de 2 casos

Con el progreso de la actual pandemia por el virus SARS-CoV-2 es cada vez mayor la evidencia científica de complicaciones en la evolución de la enfermedad. El neumotórax es una complicación común del síndrome de dificultad respiratoria aguda, el cual aumenta significativamente la mortalidad de los pacientes; sin embargo, en COVID-19 a la fecha son pocos los artículos que reportan esta complicación. A continuación se presentan dos casos de pacientes con neumonía complicada por COVID-19 con neumotórax espontáneo primario sin previa hospitalización. El primer paciente, una mujer de 63 años con hipertensión, hipotiroidismo y tabaquista, desarrolla neumonía complicada por COVID-19 con neumotórax, recuperándose progresivamente y dando de alta a los 20 días de ingreso a la unidad. El segundo paciente, un hombre de 44 años con obesidad, desarrolla neumonía complicada por COVID-19 con neumotórax, el cual durante su estancia progresa con choque séptico y fallece. La identificación oportuna de las posibles complicaciones por COVID-19 es crucial para la disminución de la mortalidad, razón por la cual deben ser sospechadas en todo tipo de pacientes con neumonía por SARS-CoV-2 en su primer ingreso a los centros de salud.

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.

Swab test in biological fluids as predictor of COVID-19 transmission risk during surgery: a prospective cross-sectional study from an Italian COVID center

BACKGROUND

The contamination of body fluids by Severe Acute Respiratory Syndrome Coronavirus 2 during surgery is current matter of debate in the scientific literature concerning CoronaVIrus Disease 2019. Surgical guidelines were published during the first wave of the COVID-19 pandemic and recommended to avoid laparoscopic surgery as much as possible, in fear that the chimney effect of high flow intraperitoneal gas escape during, and after, the procedure would increase the risk of viral transmission.

AIM

The aim of this study was to evaluate the possibility of SARS-CoV-2 transmission during surgery by searching for viral RNA in serial samplings of biological liquids.

METHODS

This is a single center prospective cross-sectional study. We used a real-time reverse transcriptase (RT) polymerase chain reaction (PCR) test to perform swab tests for the qualitative detection of nucleic acid from SARS-CoV-2 in abdominal fluids, during emergency surgery and on the first post-operative day. In the case of thoracic surgery, we performed a swab test of pleural fluids during chest drainage placement as well as on the first post-operative day.

RESULTS

A total of 20 samples were obtained: 5 from pleural fluids, 13 from peritoneal fluids and two from biliary fluid. All 20 swabs performed from biological fluids resulted negative for SARS-CoV-2 RNA detection.

CONCLUSION

To date, there is no scientific evidence of possible contagion by laparoscopic aerosolization of SARS-CoV-2, neither is certain whether the virus is effectively present in biological fluids.

An Imaging Overview of COVID-19 ARDS in ICU Patients and Its Complications: A Pictorial Review

A significant proportion of patients with COVID-19 pneumonia could develop acute respiratory distress syndrome (ARDS), thus requiring mechanical ventilation, and resulting in a high rate of intensive care unit (ICU) admission. Several complications can arise during an ICU stay, from both COVID-19 infection and the respiratory supporting system, including barotraumas (pneumothorax and pneumomediastinum), superimposed pneumonia, coagulation disorders (pulmonary embolism, venous thromboembolism, hemorrhages and acute ischemic stroke), abdominal involvement (acute mesenteric ischemia, pancreatitis and acute kidney injury) and sarcopenia. Imaging plays a pivotal role in the detection and monitoring of ICU complications and is expanding even to prognosis prediction. The present pictorial review describes the clinicopathological and radiological findings of COVID-19 ARDS in ICU patients and discusses the imaging features of complications related to invasive ventilation support, as well as those of COVID-19 itself in this particularly fragile population. Radiologists need to be familiar with COVID-19's possible extra-pulmonary complications and, through reliable and constant monitoring, guide therapeutic decisions. Moreover, as more research is pursued and the pathophysiology of COVID-19 is increasingly understood, the role of imaging must evolve accordingly, expanding from the diagnosis and subsequent management of patients to prognosis prediction.

Spectrum of Typical and Atypical Pulmonary CT Imaging Findings of COVID-19 Infection: A Retrospective Study

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first known case was identified in Wuhan, China, in December 2019. It was declared a public health emergency by WHO in January 2020. The definitive diagnostic test for COVID-19 is a real time polymerase chain reaction test (RT-PCR) which is highly specific, but sensitivity is variable. COVID-19 typically presents clinically with respiratory and systemic symptoms. The majority of the infected patients are asymptomatic during the course of the disease, which we have not included in our study. Imaging findings on high-resolution computed tomography (HRCT) chest are important to diagnose the disease in early stage, for treatment planning and to predict the patient prognosis. The purpose of our study was to characterize typical and atypical pulmonary and extra-pulmonary HRCT findings in patients with COVID-19 infection and to help in the management of patients. 

In this retrospective study, we have included 70 patients who had undergone HRCT examination of the chest in the Radiodiagnosis Department, Maharishi Markandeshwar Medical College, Kumarhatti, Solan, Himachal Pradesh, India. The HRCT findings of the chest of these patients in the study will be evaluated and data will be statistically analyzed.

Spontaneous Pneumothorax as a Late Complication of Mild COVID-19 Infection: A Case Report

Spontaneous pneumothorax (PTX) is a rare but life-threatening complication of lung injuries sustained from severe COVID-19 infection, most commonly associated with mechanical ventilation. Development of spontaneous PTX in patients after only mild COVID-19 infections not requiring hospitalization is even rarer. Here, we present the case of a 37-year-old male with spontaneous PTX secondary to a mild COVID-19 infection diagnosed one-month prior. A computed tomography (CT) scan of the chest revealed new air-filled cysts thought to be mediated by the inflammatory response to his acute infection, and his PTX was thought to be secondary to cyst wall rupture due to prolonged coughing. He was successfully treated with a chest tube and supplemental oxygen and, at a two-month follow-up, demonstrated clinical and radiographic improvement.

Epidemiological and outcome analysis of COVID-19-associated pneumothorax: multicentre retrospective critical care experience from Qatar

OBJECTIVES

To study the incidence, characteristics, treatment, associated risk factors and outcome of COVID-19-associated pneumothorax in intensive care unit (ICU).

DESIGN

Retrospective observational data review.

SETTING

A multicentre study from ICUs of three tertiary care hospitals in Qatar.

PARTICIPANTS

1788 patients with COVID-19 pneumonia requiring ICU admission from 1 March 2020 to 1 November 2020 were enrolled in this study.

INTERVENTIONS

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was to identify the incidence of COVID-19-associated pneumothorax in patients requiring ICU admission. Secondary endpoints were to determine the associated risk factors, treatment, mortality and morbidity.

RESULTS

1788 patients from 3 centres were reviewed in the study. The total episodes of pneumothorax were 75. Pneumothorax occurred in 4.2% of the patients with COVID-19 pneumonia requiring ICU admission. The majority of the subjects were male (n=72, 96%). The mean age was 55.1 (±12.7 years). The majority of the subjects were nationals of South Asian countries and the Middle East and North Africa regions. 52% (n=39) of the patients were previously healthy without comorbidities before ICU admission. The recurrence rate was 9.3%. The median length of ICU stay was 28 days (20.5-45.8 days). After developing pneumothorax, the length of mechanical ventilation ranged from 6 to 32 days, with a median of 13 days. 44% of patients eventually ended up with tracheostomy. In-hospital mortality in the patients with COVID-19-related pneumothorax was 53.3% (n=40). The odds of mortality in patients with COVID-19 pneumonia with pneumothorax is 7.15 (95% CI 4.45 to 11.48, p<0.0001) compared with those who did not develop pneumothorax. This indicates pneumothorax is a potential independent risk factor associated with mortality in patients with COVID-19 pneumonia requiring ICU admission.

CONCLUSIONS

Pneumothorax is a common complication in patients with COVID-19 requiring ICU admission, associated with poor prognosis and outcome.

TRIAL REGISTRATION NUMBER

The study was approved by the Medical Research Centre (MRC) Qatar. (MRC-01-20-1116).