Spontaneous Pneumothorax as a Rare Complication of Covid-19Viral Pneumonia: A Single-Center Retrospective Descriptive Study

Abstract

Introduction: A pneumothorax is the unusual presence of air in the pleural space; it can be spontaneous or iatrogenic with an incidence of 15% in critically ill patients. COVID-19 has a spectrum of disease ranging from mild to life threatening illness occurring in 1% of hospitalized patients. We herein describe the incidence of pneumothorax in Covid-19 hospitalized patients and present the clinical, laboratory and radiological characteristics of patients developing pneumothoraxes and its impact on total survival. Methods: This single-center retrospective study was conducted in Rafic Hariri University Hospital in Beirut, in the COVID-19 center. From a total of 2726 patients who were diagnosed with COVID-19 pneumonia according to WHO guidelines and were hospitalized between February 2020 and August 2021, 28 patients developed at least one pneumothorax during their hospital stay and were enrolled in this study. Results: From a total of 2726 patients, 28 were diagnosed to have pneumothorax and/or pneumomediastinum, with an overall incidence of 1.02% with a mortality rate of 89.3%. Twenty-one patients were males with a mean age of 54 years and 13 patients were smokers. All patients had at least one chronic disease and were found to have elevated inflammatory markers. The time from onset of symptoms to admission has a mean of 8.25 days and from admission to onset of pneumothorax 13.85 days. Fourteen patients (50%) had a large pneumothorax and 39.3% had a small pneumothorax on CT scan and 82 % were found to have patchy ground glass opacities with 17.8% having mild (<40 %) lung involvement, 35.7% having moderate (40- 70%) lung involvement and 28.5% with severe (>70%) lung involvement. Oxygen requirement varied between HFNC (67.9%) and IMV (64.3%) and all patients were on steroid therapy. Chest tube was placed in 78.6%. Discussion: The incidence of pneumothorax in COVID-19 patients was 1.02% slightly higher than other studies with a male predominance. Risk factors were variable: age, BMI, comorbidities, smoking history, use of mechanical ventilation, imaging findings, use of steroids, and increase in acute inflammatory markers. All contributed to the lung fragility and occurrence of air leak which was a bad prognostic factor leading to a mortality of 89.3% and higher morbidity and hospital stay. Pneumothorax in COVID-19 patients needs a high index of suspicion, a prompt diagnosis and a rapid treatment. Conclusion: COVID-19 viral pneumonia caused very rarely spontaneous pneumothorax that can occur at any time during the course of the disease. Mechanical ventilation, imaging’s characteristics mainly ground-glass opacities and crazy paving and use of steroids can all exacerbate the development of pneumothorax. High index of suspicion is needed for early diagnosis and appropriate treatment to decrease the length of hospital stay and the overall morbidity and mortality