Spontaneous Pneumothorax in COVID-19 Patients Treated with High-Flow Nasal Cannula outside the ICU: A Case Series

Abstract

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic and a burden to global health at the turn of 2019 and 2020. No targeted treatment for COVID-19 infection has been identified so far, thus supportive treatment, invasive and non-invasive oxygen support, and corticosteroids remain a common therapy. High-flow nasal cannula (HFNC), a non-invasive oxygen support method, has become a prominent treatment option for respiratory failure during the SARS-CoV-2 pandemic. HFNC reduces the anatomic dead space and increases positive end-expiratory pressure (PEEP), allowing higher concentrations and higher flow of oxygen. Some studies suggest positive effects of HFNC on mortality and avoidance of intubation. Spontaneous pneumothorax has been observed in patients suffering from SARS-CoV-2 pneumonia. Although the viral infection itself contributes to its development, higher PEEP generated by both HFNC and mechanical ventilation is another risk factor for increased alveoli damage and air-leak. Herein, we present three cases of patients with no previous history of lung diseases who were diagnosed with COVID-19 viral pneumonia. All of them were supported with HFNC, and all of them presented spontaneous pneumothorax.

High-Flow Nasal Cannula Oxygenation in Older Patients with SARS-CoV-2-Related Acute Respiratory Failure

“…Although the median NEW2 score was lower in the HFNCO group (8 (5-11) vs (5)(6)(7)(8) in the HCM group p = 0.016), the WHO severity score did not differ significa between the groups: 34 patients (83%) in the HFNCO group had a WHO severity sco 3 vs. 14 (76%) patients in the HCM group, p = 0.7.…”

“…HFNCO, delivering up to 60 L/min of oxygen, is a well-documented device in the supportive care of hospitalized patients with ARF, improving pre-oxygenation when intu-bation is needed and reducing mortality [5,6]. However, side effects have been reported (nasal bridge ulceration, pneumothorax, epistaxis) [7], though they have only been partially assessed in frail older adults. These side effects are comparable with those under conventional oxygen devices: mask discomfort, nasal, and oral dryness, eye irritation, nasal and eye trauma, bronchoconstriction, and gastric distention [8].…”

Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care expert consensus statement on the use of lung ultrasound in critically ill patients with coronavirus disease 2019 (ITACO)

“…On the other hand, a stable or decreasing overall LUS score after a 24-h non-invasive respiratory support trial, together with an improvement in the LUS score in the gravity dependent areas, may be associated with non-invasive respiratory support success. Furthermore, pneumothorax (PNX) and pneumomediastinum are common complications in severe COVID-19 respiratory failure [ 61 , 62 ], even in patients undergoing non-invasive ventilation, especially if associated with exacerbating inspiratory efforts and high pleural pressure swings. The role of LUS in the early detection and monitoring of PNX is well-known.…”

Air leaks in COVID-19

“…Although these strategies might delay IMV, they can still contribute to AL injury by increasing P-SILI. In addition, NIV and HFNC may be associated with a higher incidence of barotrauma than standard low-flow oxygen therapies[ 21 ]. Hence, delaying intubation and initiation of IMV may also increase the chances of AL.…”