Incidence and risk factors of COVID-19 associated pneumothorax

Abstract

Background Pneumothorax has been increasingly observed among patients with coronavirus disease-2019 (COVID-19) pneumonia, specifically in those patients who develop acute respiratory distress syndrome (ARDS). In this study, we sought to determine the incidence and potential risk factors of pneumothorax in critically ill adults with COVID-19. Method This retrospective cohort study included adult patients with laboratory-confirmed SARS-CoV-2 infection admitted to one of the adult intensive care units of a tertiary, academic teaching hospital from May 2020 through May 2021. Results Among 334 COVID-19 cases requiring ICU admission, the incidence of pneumothorax was 10% (33 patients). Patients who experienced pneumothorax more frequently required vasopressor support (28/33 [84%] vs. 191/301 [63%] P = 0.04), were more likely to be proned (25/33 [75%] vs. 111/301 [36%], P<0.001), and the presence of pneumothorax was associated with prolonged duration of mechanical ventilation; 21 (1–97) versus 7 (1–79) days, p<0.001 as well as prolonged hospital length of stay (29 [9–133] vs. 15 [1–90] days, P<0.001), but mortality was not significantly different between groups. Importantly, when we performed a Cox proportional hazard ratio (HR) model of multivariate parameters, we found that administration of tocilizumab significantly increased the risk of developing pneumothorax (HR = 10.7; CI [3.6–32], P<0.001). Conclusion Among 334 critically ill patients with COVID-19, the incidence of pneumothorax was 10%. Presence of pneumothorax was associated with prolonged duration of mechanical ventilation and length of hospital stay. Strikingly, receipt of tocilizumab was associated with an increased risk of developing pneumothorax.

Case of Spontaneous Pneumothorax After Recent COVID Pneumonia Hospitalization

“…Likewise, risk factors have not been clearly established but are postulated to include mechanical or non-invasive ventilation, ICU admission, emphysema, and tocilizumab therapy. 1 -3 The mechanism of SP formation with COVID has been thought to be due to inflammation and increased respiratory effort. 4 Our patient had 1 of these risk factors (emphysema due to COPD) but did not undergo non-invasive or mechanical ventilation nor received biologic therapy.…”

COVID-19-Related Pleural Diseases

“…Additionally, the use of tocilizumab in severe COVID-19 could potentially lead to poor lung healing and PTX, 27 but this hypothesis needs validation in large prospective studies. The role of steroids in a similar context was not found to be statistically associated with PTX in the ISARIC4C study.…”

Pneumothorax in acute respiratory distress syndrome on extracorporeal membrane oxygenation support

“…2 This incidence has remained relatively constant in the post-ARDSnet era as evidenced by recent studies of patients with COVID-19 related ARDS. 3,4 The development of a pneumothorax portends a worse prognosis in ARDS with mortality >70%. 2 The management of pneumothoraces can be difficult, particularly in patients on escalating ventilator support, and the presence of a persistent air leak can increase the rate of mortality by 26%.…”

“…Percutaneous placement 3. Maintain at least one chest tube in affected pleural space 4. Exchange over guidewire.…”