Spontaneous Pneumothorax as a Complication of Covid-19

RATIONALE Covid-19 has been associated with multi-organ complications, including pneumothoraces. Retrospective studies, which have primarily been case reports and small case series, suggest that pneumothoraces may occur in 1-2% of patients with Covid-19. This potentially lethal complication is thought to more likely occur in mechanically ventilated patients and those with underlying lung disease. Our aim is to characterize the risk factor in patients hospitalized for Covid-19 who developed pneumothoraces. METHODS We conducted a retrospective chart review of patients with COVID-19 admitted at 5 hospitals within the Inova Health System between March 1, 2020 and May 21, 2020. Out of the 1619 hospitalized patients with Covid-19, 22 patients (1.4%) developed pneumothorax. Data on demographic, comorbidities, inflammatory markers, ventilatory mode and treatment methods were collected. Findings are displayed in Table 1. RESULTS The median length of stay was 18.5 days with the diagnosis of pneumothorax made between days 1 and 30 of hospitalization. All pneumothoraces were diagnosed on chest x-ray, with the most common reason for obtaining chest imaging being respiratory distress and worsening hypoxia. 10 patients developed left-sided pneumothorax, 11 patients developed right-sided pneumothorax and 1 patient developed bilateral pneumothoraces. 8 out of the 22 patients (36%) died, whereas the crude mortality of all patients admitted with Covid-19 during this time span was 15.8%. The median age of our cohort was 60 years and 82% were male. Majority of the patients were Latino. The most common comorbidities in this cohort included hypertension (52%) and diabetes (32%). Notably, only 19% of the patients had underlying lung pathology such as chronic obstructive pulmonary disease (COPD) and asthma. Less than half of the patients who had pneumothoraces were ventilated. 16 (73%) patients had chest tubes placed for treatment. CONCLUSION The marked inflammatory response, fibrosis, and need for positive pressure ventilation in Covid-19 pneumonia are likely contributory to the development of pneumothorax. Unlike most cases of pneumothoraces, the etiology in patients with Covid-19 appears to be multifactorial and not directly associated with high vent settings. This is supported by the fact that many patients in our patients were on nasal cannula at time of diagnosis. Prompt diagnosis and treatment are crucial to mitigate morbidity and mortality in this population.