Air leaks in COVID-19

Abstract

Coronavirus disease 2019 (COVID-19) continues to create havoc and may present with myriad complications involving many organ systems. However, the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected. There is a high incidence of air leaks in patients with COVID-19, leading to acute worsening of clinical condition. The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and un-derlying lung disease. The exact pathophysiology of air leaks with COVID-19 remains unclear, but multiple factors may play a role in their development. A significant proportion of air leaks may be asymptomatic; hence, a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality. These air leaks may even develop weeks to months after the disease onset, leading to acute deterioration in the post-COVID period. Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.

Keywords: Air leak; COVID-19; Pneumomediastinum; Pneumothorax; SARS-CoV-2; Subcutaneous emphysema.

Figure 1

Macklin effect. A: Macklin effect - Increase in pressure gradient between the damaged marginal alveoli and lung interstitium due to increase in intrathoracic pressure and or decrease pulmonary intravascular pressure, leads to alveoli rupture and development of interstitial emphysema; B: Air disseminates in the peribronchovascular space up to the pulmonary hila; C: Pnemomediastinum; D: Subcutaneous emphysema; E: Pneumothorax; F: Pneumopericardium; G: Retroperitoneal emphysema.

Figure 2

Pathogenesis of air leaks in coronavirus disease 2019. COVID-19: Coronavirus disease 2019; ACE-2: Angiotensin-converting enzyme-2; P-SILI: Patient self-inflicted lung injury; VILI: Ventilator-induced lung injury.