Impact of COVID-19 pandemic on spontaneous pneumothorax

Abstract

AimDeterioration of lung parenchyma due to COVID-19 infection is considered to be responsible for the development of spontaneous pneumothorax (SP). This study aimed to compare the clinical and epidemiological features of SP diagnosed in pre-pandemic and pandemic periods.MethodsPatients who developed SP before and during the pandemic were comparatively analyzed in terms of age, gender, side of SP, type of initial treatment such as observation or chest tube insertion, requirement of additional surgery and duration of hospital stay.ResultsCases who encountered SP in the pandemic were older, required chest tubes at admission to the hospital more frequently, and stayed longer. Moreover, patients infected with COVID-19 received a higher number of subsequent surgical interventions.ConclusionTimely interventions and careful follow-up are critical to overcome the potential complications and mortality from developing SP during the COVID-19 pandemic.

Keywords

Introduction

COVID-19 (SARS-CoV-2) is a zoonotic virus first identified in Wuhan City, China, in December 2019.¹ Despite vaccine and antiviral treatment strategies, prognosis has been poor in some patients originating mostly from respiratory complications.^1-2 Recent studies have reported that pneumothorax might be present in 1% of patients who had required hospital admission, and the rate of both pneumothorax and pneumomediastinum was as high as 15% in mechanically ventilated cases.^1-2-3 Spontaneous pneumothorax (SP) is the accumulation of air in the pleural space due to causes exclusive of any traumatic and iatrogenic events. It has been described in some previously published case series as a complication of COVID-19-related severe acute respiratory syndrome comprising serious lung injury with an incidence of up to 1.7% in hospitalized patients.^2-3-4
Here, we report two series of SP, including pre-pandemic and pandemic periods. Our study aims to comparatively present the clinical and epidemiological features of the patients in both time intervals and investigate the potential differences in COVID-19 infected cases in terms of prognosis and courses of treatment.

Materials and Methods

This research was approved by the Faculty of Medical Ethics Committee (P202200011-02/7.4.22) and the Ministry of Health COVID-19 study platform (2022-02-20T18_48_17).
This study was conducted to investigate the potential effects of the COVID-19 pandemic on the development and course of SP. Fifty cases diagnosed with SP were randomly selected for pre-pandemic and pandemic periods, which were confined from November 2013 to February 2016 and March 2021 to March 2022, respectively. Cases with any sign of recent chest trauma or a past history of pneumothorax were excluded from the study. Moreover, patients who developed SP during the course of noninvasive or invasive mechanical respiratory support were not included in the study. COVID-19 infection has been approved as positive through a radiological examination and/or polymerase chain reaction (PCR) swab.
The same thoracic surgeon observed all cases, performed tube thoracostomies and performed further surgeries, all for patients with air leakage lasting more than 5 days or insufficient lung expansion. Bullectomy or wedge resection combined with partial parietal pleurectomy via axillary mini-thoracotomy was performed when required. During the pandemic, the whole group of COVID-19 patients with SP was admitted to the level 1 intensive care unit, and the follow-up was assisted by anesthesiologists and infectious diseases physicians. All patients were investigated in terms of age, gender, side of SP, type of initial treatment as observation or chest tube insertion, the requirement of additional surgery and duration of hospital stay. Comparative analysis was applied to reveal the differences regarding the potential impact of COVID-19 infection.
SPSS (IBM SPSS for Windows, ver.24) statistical package program was used for calculations. Descriptive statistics for continuous variables in the study were expressed as mean and standard deviation; categorical variables were expressed as number (n) and percentage (%). Independent Samples-T test was used to compare the averages of measurements, and the Chi-square test was employed to reveal the relationship between categorical variables. P-value <0.05 was used to indicate the statistical significance.Ethical ApprovalThis study was approved by the Scientific Research Ethics Committee of Kırklareli University Faculty of Medical School (Date: 07.04.2022, Decision No: P202200011)

Results

Mean age was 37.2 (range: 17-87) years among a total of 84 (84%) male and 16 (16%) female patients. Pneumothorax was diagnosed on the right side in 60 (60%) cases, and chest tube insertion was necessary for 84 and additional surgery for 19 patients. The mean length of in-hospital stay was 4.80 (range: 2-22) days, whereas 20 cases were diagnosed with COVID-19. Details are given in Table 1.
In comparison, the mean age was 31.1 years, and the duration of hospital stay was 3.94 days for the patients in the pre-COVID period, while these values were 43.3 years and 5.66 days for the COVID period, respectively. However, both groups did not demonstrate significant differences when examined in terms of gender, side of pneumothorax and requirement for further surgery, but cases in the COVID group underwent tube thoracostomy in larger measures. A comparison of the two periods is detailed in Table 2.
When comparing the pandemic period, cases infected and not infected with COVID-19 exhibited little diversity in demographic and clinical characteristics. Among a total of 20 COVID-positive patients, including 18 (90%) males, the mean age was 48.6 years, whereas pneumothoraxes were right-sided in 13, chest tubes were inserted in 19, additional surgeries were performed in 11 cases. Moreover, the duration of in-hospital stay was significantly longer in this group. Related data are shown in Table 3.
In summary, patients who developed SP in the pandemic demonstrated older ages, required chest tubes as the first option of initial treatment more frequently and stayed at the hospital for longer periods. Moreover, COVID-19 infected cases required a higher number of additional surgical interventions and longer hospital stays compared to disease-free individuals.
None of the patients encountered mortality or morbidity. Six of 11 COVID-19 patients who underwent additional surgery during the pandemic needed short-term home oxygen support after discharge.
Some examples of X-ray and computerized tomography (CT) images concerning SP in COVID-19 cases are given in Figure 1.

Discussion

The findings of this study clearly show that patients who developed SP during the pandemic showed distinctive clinical features such as older age or prolonged hospital stay and mainly required more challenging treatment courses to recover. The same as the well-recognized SP, COVID-19 patients have been reported to develop clinical manifestations, including chest pain, dyspnea, and inability to breathe deeply, but also radiological findings such as a linear shadow of the visceral pleura with lack of lung markings indicating collapsed lung.^5-6 Principal causes of pneumothorax in the patients with COVID-19 who did not receive mechanical ventilation were listed as alveolar damage and rupture due to pneumonia damaging the structure of lung parenchyma with inflammatory changes and comprising cystic formations and alveolar septal thickenings
^6-7-8-9
Regarding the current literature, consisting of limited case series or studies focusing on the risk factors for the development and the prognosis of SP in intubated patients with COVID-19, we were unable to compare our findings.^{8,10-11-12-13}
In comparison, patients who developed SP during the pandemic were older and more frequently required chest tube drainage due to the size of the pneumothorax and their clinical conditions. Moreover, their hospital stay was longer as a consequence of prolonged air leakage and duration of treatment. Cases with Covid-19 also underwent curative surgery more often when compared to non-COVID patients.
The development of pneumothorax has been suggested as an important prognostic marker during coronavirus infection regarding the additively arising comorbidities and complications.^5,9 Although mortality rates have been reported to be up to 70% by some earlier published studies, including a very limited number of cases, none of our patients encountered death.^8,13-14 This outcome may be due to timely interventions and attentive follow-up.
The strength of this study comes from the significant number of cases included since our hospital is the largest healthcare provider, including the only thoracic surgeon in the city. Principle limitation may be noted as the retrospective and singlecentered design. Moreover, strict boundaries were prescribed to present the clinical and surgical features of the patients more accurately.
Patients who develop spontaneous pneumothorax during COVID-19 infection require chest drainage and additional surgeries more frequently, resulting in prolonged hospital stays. Appropriate interventions and careful follow-up of patients are critical to prevent mortality.

References

1. Bıçak M, Salık F. Pneumothorax in coronavirus disease-19 patients: a retrospective case series. J Cardiovasc Thorac Anaesth Intensive Care Soc. 2020;27(3):216-222.
   PubMed · Google Scholar
2. Martinelli AW, Ingle T, Newman J, et al. COVID-19 and pneumothorax: a multicentre retrospective case series. Eur Respir J. 2020;56(5):2002697. doi:10.1183/13993003.02697-2020
   Article · PubMed · Google Scholar
3. Talan L, Şaşal SFG, Ercan U, Yenigün BM, Yüksel C, Altıntaş ND. COVID-19 pneumonia and pneumothorax: case series. Tuberk Toraks. 2020;68(4):437-443. doi:10.5578/tt.70355
   Article · PubMed · Google Scholar
4. Zantah M, Castillo ED, Townsend R, Dikengil F, Criner GJ. Pneumothorax in COVID-19 disease: incidence and clinical characteristics. Respir Res. 2020;21(1):236. doi:10.1186/s12931-020-01504-y
   Article · PubMed · Google Scholar
5. Ulutas H, Celik MR, Gulcek I, et al. Management of spontaneous pneumothorax in patients with COVID-19. Interact Cardiovasc Thorac Surg. 2022;34(6):1002-1010. doi:10.1093/icvts/ivab280
   Article · PubMed · Google Scholar
6. Ayazi S, Zebarjadi J, Grubic AD, Tahmasbi H, Ayazi K, Jobe BA. Pneumothorax as the presenting manifestation of COVID-19. J Thorac Dis. 2020;12(12):7488-7493. doi:10.21037/jtd-20-1687
   Article · PubMed · Google Scholar
7. Nunna K, Braun AB. Development of a large spontaneous pneumothorax after recovery from mild COVID-19 infection. BMJ Case Rep. 2021;14. doi:10.1136/bcr-2020-238863
   Article · PubMed · Google Scholar
8. Marzocchi G, Vassallo A, Monteduro F. Spontaneous pneumothorax as a delayed complication after recovery from COVID-19. BMJ Case Rep. 2021;14. doi:10.1136/bcr-2021-243578
   Article · PubMed · Google Scholar
9. Pehlivanlar Küçük M, Öksüz Güngör B, Küçük AO, et al. COVID-19 tanılı yoğun bakım hastalarında pnömotoraks ve subkütan amfizem olgularının değerlendirilmesi. Turk J Intensive Care. 2021;19:95-101.
   PubMed · Google Scholar
10. Udwadia ZF, Toraskar KK, Pinto L, et al. Increased frequency of pneumothorax and pneumomediastinum in COVID-19 patients admitted in the ICU: a multicentre study from Mumbai, India. Clin Med (Lond). 2021;21(6). doi:10.7861/clinmed.2021-0220
    Article · PubMed · Google Scholar
11. Yuksek SK, Parlakay AO, Guney D, Gulhan B, Bayhan GI, Senel E. A case of spontaneous pneumothorax with persistent air leakage during the course of COVID-19. Izmir Dr Behcet Uz Cocuk Hast Derg. 2021;11(2):202-205.
    PubMed · Google Scholar
12. Martelli G, Tiberio I. Pneumothorax and pulmonary air leaks as ventilator-induced injuries in COVID-19. Acute Crit Care. 2021;36(1):75-77. doi:10.4266/acc.2020.00955
    Article · PubMed · Google Scholar
13. Yassin Z, Ebrahimian M, Motamedi O, et al. Spontaneous pneumothorax and pneumomediastinum in patients with COVID-19: a case series from Iran. Clin Case Rep. 2022;10(2). doi:10.1002/ccr3.5355
    Article · PubMed · Google Scholar
14. Miró Ò, Llorens P, Jiménez S, et al. Frequency, risk factors, clinical characteristics, and outcomes of spontaneous pneumothorax in patients with coronavirus disease 2019: a case-control, emergency medicine-based multicenter study. Chest. 2021;159(3):1241-1255. doi:10.1016/j.chest.2020.11.013
    Article · PubMed · Google Scholar

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