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

Abstract

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

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

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

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

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

Keywords: COVID-19; Intubation; Length of stay; Pneumothorax; SARS-CoV-2.

Fig. 1

Consort flow diagram showing the screening and selection of the 976 RT-PCR (+) patients with chest imaging included in the data analysis. RT-PCR, reverse-transcriptase polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; CXR, chest radiograph; CT, computed tomography.

Fig. 2

53 year-old female triathlon runner with severe COVID-19 infection and multiple complications. On the day of presentation and PCR testing, AP portable radiograph (A) shows ill-defined airspace opacities in the lower lungs and small pleural effusions. The patient was intubated on hospital day (HD) 3 with repeat AP portable radiograph (B) showing worsening multifocal airspace opacities. As seen on axial (C) and coronal (D) images from a contrast-enhanced CT chest performed on HD 84, course was complicated by multiple pneumatoceles (arrows), loculated pneumothoraces (arrowheads), loculated pleural effusions (dashed arrow). Bilateral chest tubes are noted. Barotrauma and infection likely resulted in pneumatoceles with parenchymal-pleural and bronchopleural fistualization and pneumothoraces.

Fig. 3

47 year old male with history of hypertension admitted for COVID-19 pneumonia complicated by acute respiratory distress syndrome requiring intubation/tracheostomy. On the day of presentation and PCR testing, AP portable radiograph (A) shows ill-defined left lower lobe opacities. The patient was intubated on HD 2 and repeat AP radiograph (B) on HD 7 shows worsening now bilateral airspace opacities. On HD 26, AP portable radiograph (C) showed improved airspace opacities, but a new pneumotocele containing an air-fluid level in the left lung (arrow) and small pleural effusions (arrowheads). Axial (D) images from a same day contrast-enhanced CT chest show multi-septated spaces containing air and fluid, felt to represent a combination of pneumatoceles and loculated hydropneumothorax (arrowheads).

Fig. 4

Univariate and multivariable analysis of any complications for ICU stay, intubation, and successful extubation. Multivariable models were adjusted for baseline clinical non-imaging covariates with a p < 0.1 in Table 1 (age, smoking, hypertension, coronary artery disease, heart failure, presenting diastolic blood pressure and respiratory rate).

Fig. 5

Kaplan-Meier survival curve. Patients with and without any complication are represented by the red and blue curves, respectively. Patients with a complication on any CXR or CT during admission had no difference in overall survival (A) (log-rank p = 0.94). Patients with a complication on initial CXR had worse survival (B) (log-rank = 0.01), but there was not survival difference after adjusting for age, sex, respiratory rate, body mass index, diastolic blood pressure, and history of smoking, hypertension, coronary artery disease, or heart failure (adjusted HR 1.11 [0.62–1.97], p = 0.74). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)