COVID-19 and pneumothorax: a multicentre retrospective case series

Abstract

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.

FIGURE 1

Radiology and pathology in pneumothorax coronavirus disease 2019 (COVID-19). a) Anteroposterior erect chest radiograph: a male is his sixties presenting with a large right pneumothorax and some leftward tracheal shift. Background widespread bilateral alveolar opacity is consistent with “classic” COVID. b) Axial computed tomography image of the thorax acquired in a COVID-19 patient shortly before development of a right-sided pneumothorax. Note a large right-sided thin-walled cavity with air–fluid level, as well as numerous subpleural cystic spaces in the anterior hemithoraces bilaterally. c) Medium-power photomicrograph of lung parenchyma showing foci of collapse with accompanying fibrosis and vascular congestion. d) High-power image of intra-alveolar fibromyxoid plugs, fibrin and haemosiderin deposition. e) Low-power view of the 15-mm cystic space with a thick, fibrotic wall (inset: corresponding macroscopic cross-section). f) Medium-power image of the fibrous cyst wall (right) transitioning with respiratory epithelium (left), suggesting possible connection with the bronchial tree.

FIGURE 2

Mortality following pneumothorax or pneumomediastinum in coronavirus disease 2019. Kaplan–Meier survival curves from time of diagnosis of a) pneumothorax; b) pneumomediastinum. Patients at risk at each time point are indicated below each chart. Log-rank test comparing a) and b) p=0.854.

FIGURE 3

Relationship between sex, age, ventilatory support and pH and mortality in pneumothorax coronavirus disease 2019. Kaplan–Meier survival curves from time of diagnosis of pneumothorax: a) males or females log-rank test p=0.454; b) patients aged <70 years or ≥70 years log-rank test p=0.012; c) patients not intubated or receiving invasive ventilatory support with or without additional extracorporeal membrane oxygenation log-rank test p=0.173; d) patients with arterial pH ≥7.35 or <7.35 log-rank test p=0.001. Follow-up of 28 days, or to cross.