PNEUMOTHORAX IN PATIENTS WITH COVID-19 PNEUMONIA NOT ON POSITIVE PRESSURE VENTILATION: A SYSTEMATIC REVIEW OF CASE REPORTS AND SERIES

Abstract

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Many studies have been published so far describing barotrauma and volutrauma in patients with COVID-19 (SARS-COV-2) infection on non-invasive and invasive positive pressure ventilation (PPV). The pathophysiology is thought to be multifactorial with underlying lung damage, severe Acute Respiratory Distress Syndrome (ARDS), bullae formation similar to one noted in SARS(Severe Acute Respiratory Syndrome) 2004, free oxygen radical generation by over oxygenation along with atelectrauma. Steroids are routinely used now as a part of treatment regimen which might delay lung healing and hence increase the chances of lung injury. METHODS: Two databases MEDLINE and EMBASE were searched by two independent authors to find eligible studies. Out of the 704 articles reviewed, 83 individual cases met our study criteria. We included case reports and case series which described patients aged 18 years or above and were confirmed to be COVID-19 positive at the time of the event who suffered from pneumothorax (PTX) with or without evidence of other air leak syndrome (subcutaneous emphysema, pneumomediastinum or pneumopericardium) and who did not receive any form of PPV at any point of the illness. A systematic review and descriptive analysis was done. RESULTS: The mean age of the sample was 54.7 years and majority (81.9%) were males. Significant comorbidities reported include smoking (15%), underlying lung condition (7.2%) and diabetes mellitus(12%). The duration since onset of COVID symptoms to diagnosis of PTX varied largely from day 0 to day 64 with a median of 16.4(IQR=15). 45.7% of the cases were found to have PTX at admission and 10.8% were diagnosed and readmitted with PTX after recent hospitalization with COVID. 34.9% patients were noted to have evidence of other air leak syndrome and 25% had evidence of bulla on chest imaging. Majority (63.7%) of these patients were on room air since diagnosis, 17.5% on nasal cannula (NC), 10% on high flow NC and remaining 7% on non-rebreather mask. 50%(32/64) of these patients were treated with steroids for unspecified duration. 72.5% of these patients required management with a chest tube, the rest were conservatively managed. 13.2% suffered from recurrent PTX. 42% patients were admitted to intensive care unit later on, and 16.2% required mechanical ventilation. 68% of these patients unfortunately died. CONCLUSIONS: This review focuses on patients with COVID-19 who only received low pressure oxygen delivery devices or even on room air but unfortunately suffered from PTX. Obesity is known to have an association to outcomes in these patients, however majority of the cases did not report that data. Most patients with PTX notably did not have significant underlying lung condition and eventually required procedural intervention and escalation of care during the course of their illness and were associated with high rates of mortality. CLINICAL IMPLICATIONS: The current literature describes PTX in COVID-19 patients commonly as barotrauma or volutrauma secondary to PPV. Physicians should have high suspicion for PTX regardless of the mode of oxygen support in COVID-19 patients. This review calls for further studies to look closer into association of air leak syndrome in COVID- 19 patients with steroid use and bullae formation in lungs making them prone to such lung injury. DISCLOSURES: No relevant relationships by Jeeyune Bahk, source=Web Response No relevant relationships by Joseph Ghassibi, source=Web Response No relevant relationships by Christian Lo Cascio, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by DISHANT SHAH, source=Web Response