key: cord-0857196-dnrzfps2
authors: Greenberg, Daniel J.; Nabors, Christopher; Chandy, Dipak; Dhand, Abhay
title: Pneumothorax and pneumomediastinum in patients hospitalized with coronavirus disease 2019 (COVID-19)
date: 2021-02-20
journal: Heart Lung
DOI: 10.1016/j.hrtlng.2021.02.006
sha: 1308ec8b0124456e91c988358e1336529c5ab9be
doc_id: 857196
cord_uid: dnrzfps2

nan

Dear Editor,-Spontaneous Pneumothorax (PTX) has received increasing attention as a complication of Coronavirus disease 2019 (COVID-19). 1, 2 In the January article, Ekanem et al. identified PTX in 1.4% of 1619 COVID-19 who had no evidence of trauma during hospitalization. 3 Here, we describe our tertiary care center's experience with spontaneous PTX and pneumomediastinum (PTM) among patients hospitalized from March to October 2020 with laboratory confirmed COVID-19 in suburban New York. PTX and/or PTM cases were categorized as either spontaneous (primary or secondary) or as other events (present in close temporal association with trauma or a medical procedure) using prior definitions. 4 Outcomes were PTX/ PTM events, radiological resolution, recurrence, and overall mortality. During the study period, PTX and/or PTM was documented in 25/ 1260 (2%) of all hospitalized adult patients with COVID-19.

Ten of twenty-five patients had spontaneous PTX, 1/25 had spontaneous PTM and 7/25 had spontaneous PTX and PTM. In the remaining 7/25 patients, PTX/PTM occurred in close temporal relation to: a medical procedure (3/7), blunt trauma (2/7), a stab wound to the chest (1/7) and intubation (1/7). The mean duration from COVID-19 symptoms to PTX/PTM was 16 (0À46) days. Mechanical ventilation preceded PTX/PTM in 18/25 (72%) of patients by a mean of 9 (0À33) days. A low tidal volume ventilation strategy (4À8 mL/kg) was utilized for all except one study patient. Of the study patients, 52% died (13/25) at a mean of 17 (0À61) days after PTX/PTM. Two patients died shortly after development of tension PTX. The mean duration of hospital stay was 31 (2À104) days. Further details are available in the Table 1 .

This study adds importantly to the growing literature describing pulmonary complications of COVID-19. In our cohort, the overall rate of spontaneous PTX and/or PTM was 1.4% with the majority of patients being male (76%) and having no prior history of lung disease. These findings are remarkably consistent with those of Ekanum et al., who documented a spontaneous PTX rate of 1.4% with a strong male predominance. 3 In addition, we found that PTX/PTM reoccurred in around one-third of patients. The overall mortality in this cohort was 52%, while mortality was 36% in Ekanum. However, their study concluded with 4 patients remaining on mechanical ventilation or extracorporeal membrane oxygenation.

The work of Ekanum et al. and our findings indicate that COVID-19 patients are at potential risk for the development of PTX/PTM through a variety of mechanisms. Histological findings from lung tissue in patients with COVID-19 include alveolar damage with septa disruption, desquamation, edema, and exudates with fibrotic/thickened interstitial tissue. 5 This tissue damage along with other inflammatory sequelae of COVID-19 likely permits air entry into the pleural and/or mediastinal spaces causing PTX/PTM and also sets the stage for potential recurrence. In addition, COVID-19 patients frequently require mechanical ventilation and/or invasive procedures/ interventions under challenging circumstances. In Ekanum, 41% of patients were on mechanical ventilation when PTX developed and in our cohort mechanical ventilation preceded PTX/PTM in nearly three-fourths of patients.

Care of critically patients with COVID-19 is uniquely challenging due to reduced direct patient/provider contact and difficulties in transporting patients for procedures/tests. These factors may contribute to higher than usual risks of procedural complications or delays in diagnosis. Furthermore, a sudden deterioration in respiratory status of the mechanically ventilated COVID-19 patient could be attributed to progression of viral disease, pulmonary embolism, aspiration event, new or worsening ARDS or secondary bacterial infection in addition to PTX/PTM. As such, diagnosis of PTX and PTM in these patients requires a high index of clinical suspicion. Future studies designed to identify more effective ways to prevent PTX and PTM in hospitalized patients with COVID-19 are warranted. 

COVID-19 and pneumothorax: a multicentre retrospective case series

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan

Spontaneous pneumothorax: an emerging complication of COVID-19 pneumonia. Heart Lung: J Acute Crit Care

Pneumothorax: from definition to diagnosis and treatment

Late histological findings in symptomatic COVID-19 patients: a case report