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

Abstract

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.

Keywords: COVID-19; SARS-CoV-2; clinical characteristics; incidence; outcome; risk factors; spontaneous pneumothorax.

Figure 1

Study design and inclusion flow chart. COVID-19 = coronavirus disease 2019; SP = spontaneous pneumothorax; UMC-19 = Unusual Manifestations of COVID-19 project.

Figure 2

Relative frequencies and annual standardized incidence of spontaneous pneumothorax for patients with COVID-19 in the various Spanish regions. ORs were determined for COVID-19 patients with respect to non-COVID-19 patients; ORs in boldface denote statistical significance (P < .05). COVID-19 = coronavirus disease 2019.

Figure 3

Unadjusted and adjusted outcomes of patients with COVID-19 and spontaneous pneumothorax compared with patients with COVID-19 without spontaneous pneumothorax (control group A) and with non-COVID-19 patients with spontaneous pneumothorax (control group B). ∗ Calculated by Fisher exact test, using the approximation of Woolf. ∗∗ The length of hospitalization was not obtained in three of 40 case subjects. ∗∗∗ The length of hospitalization was not obtained for 23 of 387 control group B patients. COVID-19 = coronavirus disease 2019; COVID-19-non-SP = COVID-19 patients without spontaneous pneumothorax; COVID-19-SP = COVID-19 patients with spontaneous pneumothorax; non-COVID-19-SP = non-COVID-19 patients with spontaneous pneumothorax.