COVID-19 and pneumothorax: a multicentre retrospective case series

Tube Thoracostomy Complications in Patients With ARDS Requiring ECMO: Worse in COVID-19 Patients?

INTRODUCTION

The incidence and management outcomes of COVID-19 patients with acute respiratory distress syndrome (ARDS) on veno-venous extracorporeal membrane oxygenation (V-V ECMO) requiring chest tubes are not well-described. This study sought to explore differences in tube thoracostomy rates and subsequent complications between patients with and without COVID-19 ARDS on V-V ECMO.

MATERIALS AND METHODS

This study is a single institution, retrospective cohort study of patients with COVID-19 ARDS requiring V-V ECMO. The control cohort consisted of patients who required V-V ECMO for ARDS-related diagnoses from January 2018 to January 2021. The primary outcome was any complication following initial tube thoracostomy placement. Study approval was obtained from the Brooke Army Medical Center Institutional Review Board (C.2017.152d).

RESULTS

Twenty-five COVID-19 patients and 38 controls were included. Demographic parameters did not differ between the groups. The incidence of pneumothorax was not significantly different between the two groups (44% COVID-19 vs. 22% control, OR 2.8, 95% CI 0.95-7.9, P = 0.09). Patients with COVID-19 were as likely to receive tube thoracostomy as controls (36% vs. 24%, OR 1.8, 95% CI 0.55-5.7). Complications, however, were more likely to occur in the COVID-19 group (89% vs. 33%, OR 16, 95% CI, 1.6-201, P = 0.0498).

CONCLUSIONS

Tube thoracostomy placement in COVID-19 patients with ARDS requiring V-V ECMO is common, as are complications following initial placement. Clinicians should anticipate the need for re-intervention in this patient population. Small-bore (14Fr and smaller) pigtail catheters appeared to be safe and efficacious in this setting, but further study on tube thoracostomy management in ECMO patients is needed.

Secondary pneumomediastinum in COVID-19 patient: A case managed with VV-ECMO

Air leak syndrome, including pneumomediastinum (PM), pneumopericardium, pneumothorax, or subcutaneous emphysema, is primarily caused by chest trauma, cardiothoracic surgery, esophageal perforation, and mechanical ventilation. Secondary pneumomediastinum (SP) is a rare complication, with a much lower incidence reported in patients with coronavirus disease 2019 (COVID-19). Our patient was a 44-year-old nonsmoker male with a previous history of obesity (Body Mass Index [BMI] 35 kg/m2), hyperthyroidism, hypokinetic cardiopathy and atrial fibrillation in treatment with flecainide, who presented to the emergency department with 6 days of fever, cough, dyspnea, and respiratory distress. The COVID-19 diagnosis was confirmed based on a polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). After initiation of mechanical ventilation, a chest computed tomography (CT) on the first day revealed bilateral multifocal ground-glass opacities, consolidation and an extensive SP and pneumoperitoneum. Our therapeutic strategy was initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to recovery after positioning 2 drains (mediastinal and pleural), for both oxygenation and carbon dioxide clearance, to allow protective and ultra-protective ventilation to limit ventilator-induced lung injury (VILI) and the intensity of mechanical power for lung recovery. After another chest CT scan which showed a clear reduction of the PM, 2 pronation and neuromuscular relaxation cycles were also required, with improvement of gas exchange and respiratory mechanics. On the 15th day, lung function recovered and the patient was then weaned from VV-ECMO, and ultimately made a good recovery and was discharged. In conclusion, SP may be a reflection of extensive alveolar damage and should be considered as a potential predictive factor for adverse outcome in critically ill SARS-CoV2 patients.

Clinical characteristics of pneumothorax and pneumomediastinum in mechanical ventilated patients with coronavirus disease 2019: a case series

BACKGROUND

Pneumothorax (PTX) and pneumomediastinum (PM) have been reported as potential complications in patients with coronavirus disease 2019 (COVID-19); however, their risk factors and etiology remain unknown. Herein, we investigated the clinical characteristics of mechanically ventilated patients with COVID-19 with PTX or PM.

METHODS

We examined patients with severe COVID-19 requiring mechanical ventilation who were admitted to the intensive care unit of a tertiary-level emergency medical center in Tokyo, Japan between April 1, 2020. and October 31, 2021. We collected and analyzed the clinical characteristics of the patients who presented with either PTX or PM during mechanical ventilation.

RESULTS

During the study period, a total of 165 patients required mechanical ventilation, and 15 patients with PTX/PM during mechanical ventilation were selected. Three patients with obvious causes were excluded, and the remaining 12 patients were analyzed (7.3%). The mortality rate in these patients was as high as 50%, demonstrating the difficulty of treatment in the presence of PTX/PM. PTX/PM occurred 14.5 days after intubation. A peak pressure of > 30 cmH2O was only apparent in one patient, suggesting that high positive pressure ventilation may be less involved than mentioned in the literature. In addition, the inspiratory effort was not strong in our group of patients. (P0.1 was 2.1 cm H2O [1.0-3.8]).

CONCLUSION

Various factors are associated with the development of PTX/PM in patients on mechanical ventilation for COVID-19. We did not find a strong correlation between PTM/PM and barotrauma or strong inspiratory efforts, which have been identified as potential causes in previous studies.

High efficiency particulate air filters and heat & moisture exchanger filters increase positive end-expiratory pressure in helmet continuous positive airway pressure: A bench-top study

BACKGROUND

Helmet continuous positive airway pressure (CPAP) has been widely used during the COVID-19 pandemic. Specific filters (i.e. High Efficiency Particulate Air filter: HEPA; Heat & Moisture Exchanger Filter: HMEF) were used to prevent Sars-CoV2 environmental dispersion and were connected to the CPAP helmet. However, HEPA and HMEF filters may act as resistors to expiratory gas flow and increase the levels of pressure within the hood.

METHODS

In a bench-top study, we investigated the levels of airway pressure generated by different HEPA and HMEF filters connected to the CPAP helmet in the absence of a Positive End Expiratory Pressure (PEEP) valve and with two levels of PEEP (5 and 10 cmH2O). All steps were performed using 3 increasing levels of gas flow (60, 80, 100 L/min).

RESULTS

The use of 8 different commercially available filters significantly increased the pressure within the hood of the CPAP helmet with or without the use of PEEP valves. On average, the increase of pressure above the set PEEP ranged from 3 cmH2O to 10 cmH2O across gas flow rates of 60 to 100 L/min. The measure of airway pressure was highly correlated between the laboratory pressure transducer and the Helmet manometer. Bias with 95% Confidence Interval of Bias between the devices was 0.7 (-2.06; 0.66) cmH2O.

CONCLUSIONS

The use of HEPA and HMEF filters placed before the PEEP valve at the expiratory port of the CPAP helmet significantly increase the levels of airway pressure compared to the set level of PEEP. The manometer can detect accurately the airway pressure in the presence of HEPA and HMEF filters in the helmet CPAP and its use should considered.

Subcutaneous emphysema, pneumomediastinum and pneumothorax in COVID-19 pneumonia-independent prognostic factors

The ongoing coronavirus disease 2019 pandemic has created a substantial disease burden and morbidity. However, the development of subcutaneous emphysema, pneumomediastinum, and pneumothorax have been of rare occurrence and their significance in mortality has not been studied. In a retrospective single-institution observational study at a tertiary care centre in the northern part of India, we evaluated the occurrence of these complications and their relationship with mortality from 1 June 2020 to 30 November 2020. All coronavirus disease 2019 (COVID-19) patients developing subcutaneous emphysema, pneumomediastinum, and pneumothorax were included. Cardiopulmonary resuscitation-induced complications were excluded. Measured endpoints were either discharge to home or death. There were 3145 COVID-19 patients admitted during the study period. Altogether, 38 patients developed one of these complications or in combination. There were 33 male and 5 female patients with an age range from 23 to 95 years, mean 57 ± 12.7. 36 of 38 patients developed these complications while on the ventilator and required chest drain insertions as a part of management. Two patients developed these complications while breathing spontaneously. The incidence of these complications among ventilated patients was 22.9% (36/157). 32 of 38 died giving a mortality of 84.21%. The average time from the development of these complications to death was 8.4 days (range 2-27 days). We conclude that lung changes in COVID-19 patients make them prone to the development of air leaks. Subcutaneous emphysema, pneumomediastinum, and pneumothorax were more common in ventilated patients but were also observed in spontaneously breathing patients. These complications were associated with significantly high mortality in COVID-19 patients (p-value = 0.0002 by Chi-square test).

Clinical features of pneumothorax associated with COVID-19: A retrospective analysis of two centres

BACKGROUND

Pneumothorax is a known sequela of coronavirus disease 2019 (COVID-19). However, the clinical features of pneumothorax associated with COVID-19 have not been fully elucidated.

METHODS

Patients who developed pneumothorax within 6 months of being diagnosed with COVID-19 were retrospectively analysed at two institutions. We investigated the background factors, COVID-19 severity and treatment, timing of pneumothorax onset, treatment modalities, treatment duration, and prognosis of these patients.

RESULTS

A total of 21 patients were diagnosed with pneumothorax within 6 months of COVID-19 diagnosis. The combined incidence rate of pneumothorax at two institutions was 0.89 %. The mean age of these patients was 72.5 years, and they were predominantly male (90.5 %), with a history of smoking (76.1 %). The most frequent comorbidity was hypertension, followed by type 2 diabetes mellitus, COPD, and malignancy. Approximately 76 % of the patients had moderate or severe disease requiring oxygenation. Moreover, 90.5 % of these patients were taking antiviral drugs; 52.4 %, immunosuppressant agents (baricitinib/tocilizumab); and 66.7 % were on dexamethasone. The median time to the onset of pneumothorax was 15.0 days, and 86 % of cases occurred within 1 month of COVID-19 diagnosis. Bilateral pneumothorax and pneumomediastinum were noted in one patient each. Chest drainage was performed in 71.4 % of the patients. The mean treatment duration for pneumothorax was 14.1 days, and the 30-day mortality rate was 28.6 %.

CONCLUSION

Pneumothorax associated with COVID-19 was more common in patients with moderate or severe disease requiring oxygenation, and occurred within 1 month of COVID-19 diagnosis. Pneumothorax associated with COVID-19 is a serious complication with a high mortality rate and clinicians should pay attention to it.

Pop Goes the Lung: Bilateral Pneumothoraces Due to Delayed Pneumatocele Rupture in Coronavirus Disease 2019 (COVID-19)

Worldwide medical and scientific communities are focusing on further understanding coronavirus disease 2019 (COVID-19) complications and its long-term impact on survivors. Pneumatocele cases are being reported more as a consequence of this virus and a cause of pneumothorax in certain patients. In this case vignette, we present a previously healthy male with COVID-19 symptoms who required hospitalization for hypoxia and who required readmission for bilateral pneumothorax from the delayed rupture of pneumatoceles. We describe this rare pathology and provide hypotheses for possible etiologies.

Pneumomediastinum and pneumothorax in acute respiratory distress syndrome (ARDS) patients: a narrative review

Background and Objective

Acute respiratory distress syndrome (ARDS) is a severe, life-threatening medical condition characterized by poor oxygenation due to non-compliant lungs secondary diffuse alveolar damage. Encouragingly, the incidence of ARDS has declined steadily recently, attributed mainly to implementation of keystone guidelines and continuous research efforts. Mechanical ventilation is the cornerstone of supportive care for ARDS patients. This review aims to consolidate the current knowledge on pneumothorax (PNX) and pneumomediastinum (PMD) and to enhance the understanding of the readers. The objectives are to (I) explore the etiology and risk factors of PNX and PMD, (II) discuss the various diagnostic modalities available, (III) evaluate management options, and (IV) recent advancements.

Methods

A search of the literature was conducted using PubMed, MEDLINE, and Google Scholar for relevant articles pertaining to PNX and PMD in ARDS population. The clinical presentation, diagnostic and management strategies of PNX, PMD, and ARDS were summarized, and all authors reviewed the selection and decide which studies to include.

Key Content and Findings

The adoption of lung-protective ventilation strategies, based on the review of literature from the recent years, shows that it has played a significant role in reducing the occurrence of barotrauma, such as PNX and PMD. However, PNX and PMD remains to be a challenging complication to manage. With a specific focus on PNX and PMD, this review provides valuable insights into effectively managing and understanding these critical complications among ARDS patients.

Conclusions

ARDS, with its evolving definition, continues to pose a life-threatening threat. Despite the widespread adoption of lung-protective ventilation strategies, PNX and PMD present persistent challenges in management. Further research is imperative to enhance the risk assessment of ARDS patients prone to developing PNX and PMD and to institute more effective prevention and treatment measures.

A Case of Bilateral Pneumothorax With COVID-19 Infection

Bilateral spontaneous pneumothorax is a serious complication of coronavirus disease 2019 (COVID-19). The incidence of any spontaneous pneumothorax in patients with the aforementioned viral infection when hospitalized is about 1%. Treatment can involve management such as oxygen support, tube thoracostomy, pleurodesis, or even invasive surgery. The associated mortality with this complication is about 33% to 52%. We present a case of bilateral pneumothorax in a patient diagnosed with COVID-19 without any history of smoking or underlying lung disease. Careful vigilance and close monitoring of this serious complication are mandatory in inpatients.

Delayed diagnosis of Lemierre's syndrome in a patient with severe coronavirus disease 2019: importance of comprehensive oral and neck examination - a case report

BACKGROUND

Given the widespread prevalence of the coronavirus disease 2019 (COVID-19), oral and neck examinations tend to be avoided in patients with suspected or confirmed COVID-19. This might delay the diagnosis of conditions such as Lemierre's syndrome, which involves symptoms resembling COVID-19-related throat manifestations.

CASE PRESENTATION

A 24-year-old man without any underlying conditions was diagnosed with COVID-19 7 days before presentation. He was admitted to another hospital 1 day before presentation with severe COVID-19 and suspected bacterial pneumonia; accordingly, he was started on treatment with remdesivir and meropenem. Owing to bacteremic complications, the patient was transferred to our hospital for intensive care. On the sixth day, the patient experienced hemoptysis; further, a computed tomography (CT) scan revealed new pulmonary artery pseudoaneurysms. Successful embolization was performed to achieve hemostasis. In blood cultures conducted at the previous hospital, Fusobacterium nucleatum was isolated, suggesting a cervical origin of the infection. A neck CT scan confirmed a peritonsillar abscess and left internal jugular vein thrombus; accordingly, he was diagnosed with Lemierre's syndrome. The treatment was switched to ampicillin/sulbactam, based on the drug susceptibility results. After 6 weeks of treatment, the patient completely recovered without complications.

CONCLUSION

This case highlights the significance of thorough oral and neck examinations in patients with suspected or diagnosed COVID-19 for the detection of throat and neck symptoms caused by other conditions.

Ventilatory associated barotrauma in COVID-19 patients: A multicenter observational case control study (COVI-MIX-study)

BACKGROUND

The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication.

METHODS

This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death.

RESULTS

We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001).

CONCLUSIONS

C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality.

TRIAL REGISTRATION

this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021).

Non-Ventilated Patients with Spontaneous Pneumothorax or Pneumomediastinum Associated with COVID-19: Three-Year Debriefing across Five Pandemic Waves

Spontaneous pneumothorax and pneumomediastinum (SP-SPM) are relatively rare medical conditions that can occur with or independently of COVID-19. We conducted a retrospective analysis of SP-SPM cases presented to the emergency departments (EDs) of two University-affiliated tertiary hospitals from 1 March 2020 to 31 October 2022. A total of 190 patients were identified: 52 were COVID-19 cases, and 138 were non-COVID-19 cases. The primary outcome we were looking for was in-hospital mortality. The secondary outcomes concerned the disease severity assessed by (a) days of hospitalization; (b) required mechanical ventilation (MV); and (c) required intensive care (IC). All were investigated in the context of the five pandemic waves and the patients' age and comorbidities. The pandemic waves had no significant effect on the outcomes of these patients. Logistic regression found age (OR = 1.043; 95%CI 1.002-1.085), COVID-19 (OR = 6.032; 95%CI 1.757-20.712), number of comorbidities (OR = 1.772; 95%CI 1.046-3.001), and ground-glass opacities over 50% (OR = 5.694; 95%CI 1.169-27.746) as significant risk predictors of in-hospital death while controlling for gender, smoking, the pandemic wave, and the extension of SP-SPM. The model proved good prediction performance (Nagelkerke R-square = 0.524) and would hold the same significant predictors for MV and IC.

Lung ultrasound-guided PEEP titration in COVID-19 patients treated with CPAP

OBJECTIVES

An increasing number of COVID-19 patients were treated with continuous positive airways pressure (CPAP). To evaluate the clinical effects of personalized positive end-expiratory pressure (PEEP) compared to standard fixed PEEP in COVID-19 patients requiring CPAP.

METHODS

This is a single center, prospective, randomized clinical study. Sixty-three COVID-19 patients with hypoxemic respiratory failure and bilateral pneumonia were randomized in two Groups: Group A received CPAP with fixed PEEP of 10 cm H2O, Group B performed the "PEEP trial", that consists in the evaluation of best PEEP defined as the PEEP value that precedes the echographic appearance of "lung pulse" determining a PaO2/FiO2 increase. Primary outcome was composite in-hospital mortality + intubation, secondary outcome was the percentage increase of PaO2/FiO2. As safety indicator, the incidence of pneumothorax was collected.

RESULTS

Thirty-two patients were enrolled in Group A and 31 in Group B. The two groups were comparable for clinical characteristics and laboratory parameters. The primary outcome occurred in 36 (57.1 %) patients: 23 (71.8 %) in Group A and 13 (41.9 %) in Group B (p<0.01). Mortality was higher in Group A (53.1 vs. 19.3 %, p<0.01), while intubation rate was comparable between groups. Group B showed a higher PaO2/FiO2 increase than Group A (34.9 vs. 13.1 %, p<0.01). Five cases of pneumothorax were reported in Group A, none in Group B.

CONCLUSIONS

Lung ultrasound-guided PEEP trial is associated with lower mortality in COVID-19 patients treated with CPAP. Identifying the best PEEP is useful to increase oxygenation and reduce the incidence of complications.

Incidence of Air Leak Syndrome in Pediatric Patients With SARS-COV-2 Pneumonia and Respiratory Failure: A Single-Center Retrospective Study

Air leak syndrome (ALS) is defined as the extrusion of air from an aerated compartment into an unaerated compartment with associated symptoms of respiratory distress. This syndrome can occur as a consequence of trauma, iatrogenic causes, or spontaneously. Retrospective investigations conducted in the adult population have demonstrated an elevated risk of spontaneous ALS development in patients with coronavirus disease 2019 (COVID-19) pneumonia, along with its correlation with mortality. However, no studies have yet explored this phenomenon within the pediatric population. In light of this knowledge gap, we conducted a retrospective chart review comprising 128 pediatric patients ranging in age from one month to 18 years. The primary objective was to assess the incidence of ALS in two distinct groups: patients diagnosed with COVID-19 pneumonia and those with non-COVID-19 viral pneumonia. The groups were compared using Fisher's exact test for sex, the presence of ALS, the requirement of extracorporeal membrane oxygenation (ECMO), and death. The modified Wald method was used to calculate the 95% confidence interval for the mortality rate in patients with COVID-19 pneumonia in the presence of ALS. Our findings revealed a higher prevalence of ALS in patients with COVID-19 pneumonia compared to the non-COVID-19 viral pneumonia group, with a statistically significant P-value of 0.02 and an odds ratio (OR) of 6.72. In terms of mortality rates, there was a statistically significant difference between the two groups (P = 0.025, OR = 1.083). In addition, in patients with ALS in the presence of COVID-19 pneumonia, the mortality rate was 37.5%. However, the requirement of ECMO was not statistically significant (P = 0.16, OR = 1.04). These results suggest that patients with COVID-19 pneumonia have an increased mortality rate and a heightened risk of developing ALS compared to individuals with other viral pneumonias. Furthermore, the presence of ALS was associated with a high mortality rate in COVID-19 pneumonia patients. However, it is crucial to note that obtaining a larger patient sample and involving multiple institutions would be necessary to obtain more consistent and robust data.

COVID-19-Related Pleural Diseases

Coronavirus disease 2019 (COVID-19)-related pleural diseases are now well recognized. Since the beginning of the pandemic, increasing cases of pleural diseases including pneumothorax, pneumomediastinum, and pleural effusion with severe COVID-19 infection have attracted the attention of physicians and are not incidental or due to barotrauma. The complicated course of COVID-19 illness highlights the complex pathophysiological underpinnings of pleural complications. The management of patients with pneumothorax and pneumomediastinum is challenging as the majority require assisted ventilation; physicians therefore appear to have a low threshold to intervene. Conversely, pleural effusion cases, although sharing some similar patient characteristics with pneumothorax and pneumomediastinum, are in general managed more conservatively. The evidence suggests that patients with COVID-19-related pleural diseases, either due to air leak or effusion, have more severe disease with a worse prognosis. This implies that prompt recognition of these complications and targeted management are key to improve outcomes.

A Pictorial Essay Describing the CT Imaging Features of COVID-19 Cases throughout the Pandemic with a Special Focus on Lung Manifestations and Extrapulmonary Vascular Abdominal Complications

With the Omicron wave, SARS-CoV-2 infections improved, with less lung involvement and few cases of severe manifestations. In this pictorial review, there is a summary of the pathogenesis with particular focus on the interaction of the immune system and gut and lung axis in both pulmonary and extrapulmonary manifestations of COVID-19 and the computed tomography (CT) imaging features of COVID-19 pneumonia from the beginning of the pandemic, describing the typical features of COVID-19 pneumonia following the Delta variant and the atypical features appearing during the Omicron wave. There is also an outline of the typical features of COVID-19 pneumonia in cases of breakthrough infection, including secondary lung complications such as acute respiratory distress disease (ARDS), pneumomediastinum, pneumothorax, and lung pulmonary thromboembolism, which were more frequent during the first waves of the pandemic. Finally, there is a description of vascular extrapulmonary complications, including both ischemic and hemorrhagic abdominal complications.

Spontaneous tension pneumomediastinum with pneumothorax and subcutaneous emphysema as a complication of COVID-19 disease

Recently spontaneous tension pneumomediastinum (STM), were reported as infrequent complications in coronavirus disease 2019 (COVID-19) patients but pneumothorax (PT), and subcutaneous emphysema (SE) are more frequently seen in COVID-19 patients. PT and SE may present after PTM in COVID-19. The aim of this presentation is to show the complications of STM in an Iranian patients with COVID-19 disease with PT and SE, who were hospitalized in Arya hospital, Rasht, Iran. For 3 months, we followed these patients and their condition was good. STM are uncommon complications in COVID-19 patients and were reported frequently in male patients. Early diagnosis and treatment could save the patients as these complications are related to poor prognosis and prolonged hospitalization. Patients with mild COVID-19 and mild pulmonary damage may have a favorable outcome.

The prognostic effect of concomitant COVID-19 with spontaneous pneumothorax

Background

The aim of this study was to investigate the prevalence of novel coronavirus disease 2019 (COVID-19) in patients hospitalized with primary spontaneous pneumothorax and to evaluate its possible effects on the clinical course, treatment, and the prognosis.

Methods

Between April 2020 and January 2021, a total of 86 patients (78 males, 8 females; mean age: 27±5 years; range, 16 to 40 years) who had no underlying lung disease and were diagnosed with the first episode of spontaneous pneumothorax were retrospectively analyzed. At the same time of diagnosis, all patients were screened for COVID-19 via polymerase chain reaction test of nasopharyngeal swabs. According to the test results, the patients were divided into two groups as COVID-19(+) and COVID-19(-). The duration of air leak, hospital stay, recurrence rates and treatment modalities, and mortality rates of the two groups were compared.

Results

Following a pneumothorax diagnosis, 18 (21%) patients were diagnosed with COVID-19. In COVID-19(+) patients, the mean air leak and lung expansion duration were significantly longer (p<0.0001 for both). In these patients, the mean length of hospital stay was also significantly longer (p<0.0001). During the median follow-up of six months, no mortality was observed and the recurrence rate was similar between the two groups (p=0.998).

Conclusion

Our study results suggest that COVID-19 negatively affects the recovery time in patients with spontaneous pneumothorax.

Pneumothorax, pneumomediastinum, and subcutaneous emphysema in hospitalized COVID-19 patients: incidence, clinical characteristics, and outcomes

BACKGROUND

Limited data is available on the incidence and outcomes of pneumothorax (PTX), pneumomediastinum (PNM), and subcutaneous emphysema (SCE) in COVID-19 patients. This study aimed to investigate the characteristics of these complications in hospitalized COVID-19 patients.

RESEARCH DESIGN AND METHODS

A retrospective study was conducted, involving adult COVID-19 patients admitted to Mayo Clinic Florida from 03/2020-06/2022. Patients were divided into two groups based on the presence or absence of PTX/PNM/SCE.

RESULTS

1926 hospitalized patients with COVID-19 were included, of which 518 were admitted to the ICU. The incidence of PTX/PNM/SCE was 6.3%. Patients with these complications were more likely to be male, Asian, and unvaccinated. Conversely, they were less likely to have chronic obstructive pulmonary disease. Patients who developed PTX/PNM/SCE after 72 hours of admission were more likely to receive high-dose corticosteroids and for an extended duration. The affected group had an adjusted odds ratio for in-hospital mortality of 13.32 (95%CI, 8.19-21.59) and ICU admission of 9.14 (95%CI, 5.3-12.78) compared to the unaffected group.

CONCLUSION

Although the occurrence of PTX/PNM/SCE in hospitalized COVID-19 patients was rare, it was associated with worse outcomes. Corticosteroids may contribute to the pathogenesis of these complications; however, further studies are needed to investigate this relationship in more detail.

How fit are military hyperbaric personnel after an asymptomatic or mild symptomatic COVID-19 infection? A retrospective study

INTRODUCTION

In the diving community there is a special need to know if asymptomatic or mild COVID-19 disease impacts the cardiopulmonary functioning of individuals with occupational exposure to extreme environments. To date, no controlled studies have been conducted comparing COVID-19-infected hyperbaric employees and non-COVID-19-infected peers in a military setting.

METHODS

Between June 2020 and June 2021, healthy, hyperbaric, military personnel aged between 18 and 54 years old, who had recovered from asymptomatic or subclinical COVID-19 disease at least one month earlier, were analysed. Non-COVID-infected peers with medical assessments during the same period were used as the control group. Somatometry, spirometry, VO₂ max, and DLCO were measured for each group.

RESULTS

No clinically relevant differences in somatometry, lung function tests, and exercise testing were found between the COVID-19 group and the controls. However, the percentage of individuals with a decrease in estimated VO2-max of 10% or more was significantly greater in the COVID group than in the control group (24 vs. 7.8%, P = 0.004).

CONCLUSIONS

After asymptomatic or mild symptomatic COVID-19 infections, military hyperbaric employees are as fit as those who had not encountered COVID-19. As this research was based on a military population, it cannot be extrapolated to a nonmilitary population. Further studies in nonmilitary populations are necessary to determine the medical relevance of the present findings.

Pneumomediastinum in patients with COVID-19 undergoing CT pulmonary angiography: a retrospective cohort study

BACKGROUND

Various complications have been reported in patients with COVID-19 including pneumomediastinum.

METHODS

The primary objective of the study was to determine the incidence of pneumomediastinum in COVID-19 positive patients who underwent CT pulmonary angiography (CTPA). The secondary objectives were to analyse if the incidence of pneumomediastinum changed between March and May 2020 (peak of the first wave in the UK) and January 2021 (peak of the second wave in the UK) and to determine the mortality rate in patients with pneumomediastinum. We undertook an observational, retrospective, single-centre, cohort study of patients with COVID-19 admitted to Northwick Park Hospital.

RESULTS

74 patients in the first wave and 220 patients in the second wave met the study criteria. Two patients during the first wave and eleven patients during the second wave developed pneumomediastinum.

CONCLUSIONS

The incidence of pneumomediastinum changed from 2.7% during the first wave to 5% during the second wave and this change was not statistically significant (p value 0.4057). The difference in mortality rates of patients with pneumomediastinum in both waves of COVID-19 (69.23%) versus patients without pneumomediastinum in both waves of COVID-19 (25.62%) was statistically significant (p value 0.0005). Many patients with pneumomediastinum were ventilated, which could be a confounding factor. When controlling for ventilation, there was no statistically significant difference in the mortality rates of ventilated patients with pneumomediastinum (81.81%) versus ventilated patients without pneumomediastinum (59.30%) (p value 0.14).

Bilateral spontaneous pneumothorax as a late complication of COVID-19, a clinical case report

Key Clinical Message

Bilateral spontaneous pneumothorax and sudden dyspnea can occur as late complication in patients with COVID-19 even without any history of mechanical ventilation usage.

Abstract

Bilateral spontaneous pneumothorax can occur as a late complication in patients with COVID-19, even without any history of mechanical ventilation. Here, we present a patient with mild COVID-19 pneumonia with a left massive pneumothorax in the third week of hospitalization and the addition of a right pneumothorax.

Barotrauma during Noninvasive Respiratory Support in COVID-19 Pneumonia Outside ICU: The Ancillary COVIMIX-2 Study

BACKGROUND

Noninvasive respiratory support (NIRS) has been extensively used during the COVID-19 surge for patients with acute respiratory failure. However, little data are available about barotrauma during NIRS in patients treated outside the intensive care unit (ICU) setting.

METHODS

COVIMIX-2 was an ancillary analysis of the previous COVIMIX study, a large multicenter observational work investigating the frequencies of barotrauma (i.e., pneumothorax and pneumomediastinum) in adult patients with COVID-19 interstitial pneumonia. Only patients treated with NIRS outside the ICU were considered. Baseline characteristics, clinical and radiological disease severity, type of ventilatory support used, blood tests and mortality were recorded.

RESULTS

In all, 179 patients were included, 60 of them with barotrauma. They were older and had lower BMI than controls (p < 0.001 and p = 0.045, respectively). Cases had higher respiratory rates and lower PaO₂/FiO₂ (p = 0.009 and p < 0.001). The frequency of barotrauma was 0.3% [0.1-1.3%], with older age being a risk factor for barotrauma (OR 1.06, p = 0.015). Alveolar-arterial gradient (A-a) DO₂ was protective against barotrauma (OR 0.92 [0.87-0.99], p = 0.026). Barotrauma required active treatment, with drainage, in only a minority of cases. The type of NIRS was not explicitly related to the development of barotrauma. Still, an escalation of respiratory support from conventional oxygen therapy, high flow nasal cannula to noninvasive respiratory mask was predictive for in-hospital death (OR 15.51, p = 0.001).

CONCLUSIONS

COVIMIX-2 showed a low frequency for barotrauma, around 0.3%. The type of NIRS used seems not to increase this risk. Patients with barotrauma were older, with more severe systemic disease, and showed increased mortality.

A Case Series of Persistent SARS-CoV-2 Infection in Immunocompromised Pediatric Patients

Diagnosis and management of SARS-CoV-2 infection in immunocompromised patients are extremely challenging. These patients can have atypical clinical courses, and there is a paucity of data regarding clinical features, diagnostic findings, and the safety and efficacy of available therapeutic agents used to treat COVID-19 in these patients. In this case series, we report atypical COVID-19 presentations in 4 immunocompromised pediatric patients who were admitted with acute respiratory failure after an initial diagnosis of COVID-19 a few weeks earlier. All patients included in this cohort showed persistent worsening respiratory symptoms for several weeks before hospital presentation. While they manifested common COVID-19 sequelae, they also had rare COVID-19-related pathognomonic and radiographic features developed along their hospital course. Multiple therapeutic agents were used in their COVID-19 management, including corticosteroids, remdesivir, and monoclonal antibodies. All three patients who have received concurrent therapy with remdesivir, hydrocortisone, and monoclonal antibodies survived, and only one patient died as a direct complication of COVID-19 ARDS with secondary pulmonary mucormycosis. Our outcomes suggest the potential benefit of remdesivir use in combination with hydrocortisone and monoclonal antibodies in the management of severe COVID-19 ARDS in this group, as well as the importance of close surveillance and early administration of broad empirical antimicrobial and antifungal coverage if clinically indicated in this high-risk population.

Predictors of Pneumothorax in People With COVID-19 Pneumonia: A Multicenter Retrospective Investigation

This multicenter retrospective investigation aimed to identify predictors of pneumothorax (PTX), pneumomediastinum (PM), and subcutaneous emphysema (SE) in patients with COVID-19 pneumonia admitted to the ICU. A total of 256 patients were included, with 128 in the case group and 128 in the control group. The study sample consisted of predominantly male patients with a mean age of around 53 years and a high prevalence of comorbidities. Significant predictors of PTX, PM, and SE included the presence of coronary artery disease, non-rebreather mask usage, high-flow oxygen therapy, mechanical ventilation, pressor usage, inpatient dialysis, steroid usage, sedative usage, narcotic usage, paralytic usage, elevated C-reactive protein levels, increased lung infiltration, the presence of PM and SE, mode of ventilation, duration of various respiratory support interventions, and severity of illness as indicated by APACHE and SOFA scores. These findings have important implications for the clinical management of patients with COVID-19 pneumonia, as they may help identify and closely monitor at-risk individuals, allowing for timely intervention and potentially improving clinical outcomes. Future research should focus on validating these predictors in larger cohorts and investigating the underlying mechanisms to develop targeted preventive and therapeutic strategies.

Lung Abscess and Pyothorax in Critically Ill COVID-19 Patients: A Single-Center Retrospective Study

The mortality rate of patients with COVID-19 pneumonia requiring mechanical ventilation remains high. This study determined the percentage and characteristics of patients who developed lung abscesses or pyothorax and their mortality rates among adult patients with COVID-19 admitted to the ICU who required mechanical ventilation. Of the 64 patients with COVID-19 assessed, 30 (47%) developed ventilator-associated pneumonia (VAP), of whom 6 (20%) developed pyothorax or lung abscess. There were no statistically significant differences in patient characteristics, treatment after ICU admission, or outcomes between those with and without these complications, except for age. VAP complicated by Lung abscess or pyothorax was caused by a single organism, with Staphylococcus aureus (n = 4) and Klebsiella species (n = 2) being the primary causative agents. Occur infrequently in patients with COVID-19 requiring mechanical ventilation. Large-scale studies are required to elucidate their effects on clinical outcomes.

Incidence, outcomes and risk factors of barotrauma in veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome

BACKGROUND

Although acute respiratory distress syndrome (ARDS) patients are provided a lung rest strategy during extracorporeal membrane oxygenation (ECMO) treatment, the exact conditions of barotrauma is unclear. Therefore, we analyzed the epidemiology and risk factors for barotrauma in ARDS patients using ECMO in a single, large ECMO center in China.

METHODS

A retrospective analysis was performed on 127 patients with ARDS received veno-venous (VV) ECMO who met the Berlin definition. The epidemiology and risk factors for barotrauma during ECMO were analyzed.

RESULTS

Among 127 patients with ARDS treated with ECMO, barotrauma occurred in 24 (18.9%) during ECMO and 9 (7.1%) after ECMO decannulation, mainly in the late stage of ARDS (75%) and ≥8 days during ECMO (54.2%). Univariate and multivariate analyses showed that younger ARDS patients (OR = 0.953, 95%CI 0.923-0.983, p = 0.003) and those with pneumocystis jirovecii pneumonia (PJP) (OR = 3.15, 95%CI 1.070-9.271, p = 0.037), elevated body temperature after establishing ECMO (OR = 2.997, 95%CI 1.325-6.779, p = 0.008) and low platelet count after establishing ECMO (OR = 0.985, 95%CI 0.972-0.998, p = 0.02) had an increased risk of barotrauma during ECMO. There was no difference in ventilator parameters between patients with and without barotrauma. Barotrauma during ECMO was mainly related to the etiology of the disease and disease state.

CONCLUSION

There is a high incidence of barotrauma in ARDS patients during ECMO, even after ECMO decannulation. Young age, PJP, elevated body temperature and low platelet count after establishing ECMO are risk factors of barotrauma, and those patients should be closely monitored by imaging, especially in the late stage of ARDS.

A Case of Pneumothorax Ex Vacuo Associated with COVID-19

Pneumothorax is a known complication of coronavirus disease 2019 (COVID-19). The concept of pneumothorax ex vacuo has also been proposed to describe pneumothorax that occurs after malignant pleural effusion drainage. Herein, we present the case of a 67-year-old woman who had abdominal distension for 2 months. A detailed examination led to the suspicion of an ovarian tumor and revealed an accumulation of pleural effusion and ascitic fluid. Thoracentesis was performed, raising the suspicion of metastasis of high-grade serous carcinoma arising from the ovary. An ovarian biopsy was scheduled to select subsequent pharmacotherapy, and a drain was inserted preoperatively into the left thoracic cavity. Thereafter, a polymerase chain reaction analysis revealed that the patient was positive for COVID-19. Thus, the surgery was postponed. After the thoracic cavity drain was removed, pneumothorax occurred, and mediastinal and subcutaneous emphysema was observed. Thoracic cavity drains were then placed again. The patient’s condition was conservatively relieved without surgery. This patient may have developed pneumothorax ex vacuo during the course of a COVID-19 infection. Since chronic inflammation in the thoracic cavity is involved in the onset of pneumothorax ex vacuo, careful consideration is required for the thoracic cavity drainage of malignant pleural effusion and other fluid retention.

Innovative treatment of hypercapnia with soda lime in COVID-19: a case report

One of the rare consequences of COVID-19 is increasing blood carbon dioxide, which can lead to unconsciousness, dysrhythmia, and cardiac arrest. Therefore, in COVID-19 hypercarbia, non-invasive ventilation (with Bi-level Positive Airway Pressure, BiPAP) is recommended for treatment. If CO₂ does not decrease or continues rising, the patient's trachea must be intubated for supportive hyperventilation with a ventilator (Invasive ventilation). The high morbidity and mortality rate of mechanical ventilation is an important problem of invasive ventilation. We launched an innovative treatment of hypercapnia without invasive ventilation to reduce morbidity and mortality. This new approach could open the window for researchers and therapists to reduce COVID death. To investigate the cause of hypercapnia, we measured the carbon dioxide of the airways (mask and tubes of the ventilator) with a capnograph. Increased carbon dioxide inside the mask and tubes of the device was found in a severely hypercapnic COVID patient in the Intensive Care Unit (ICU). She had a 120kg weight and diabetes disease. Her PaCO₂ was 138mmHg. In this condition, she had to be under invasive ventilation and accept its complication or lethal risk but we decreased her PaCO₂ with the placement of a soda lime canister in the expiratory pathway to absorb CO₂ from the mask and ventilation tube. Her PaCO₂ dropped from 138 to 80, and the patient woke up from drowsiness completely without invasive ventilation, the next day. This innovative method continued until PaCO₂ reached 55 and she was discharged home 14 days later after curing her COVID. Soda lime is used for carbon dioxide absorption in anesthesia machines and we can research its application in hypercarbia state in ICU to postpone invasive ventilation for treatment of hypercapnia.

Pneumothorax in hospitalized COVID-19 patients with severe respiratory failure: Risk factors and outcome

PNX was described as an uncommon complication in COVID-19 patients but clinical risk predictors and the potential role in patient's outcome are still unclear. We assessed prevalence, risk predictors and mortality of PNX in hospitalized COVID- 19 with severe respiratory failure performing a retrospective observational analysis of 184 patients admitted to our COVID-19 Respiratory Unit in Vercelli from October 2020 to March 2021. We compared patients with and without PNX reporting prevalence, clinical and radiological features, comorbidities, and outcomes. Prevalence of PNX was 8.1% and mortality was >86% (13/15) significantly higher than in patients without PNX (56/169) (P < 0.001). PNX was more likely to occur in patients with a history of cognitive decline (HR: 31.18) who received non-invasive ventilation (NIV) (p < 0.0071) and with low P/F ratio (HR: 0.99, p = 0.004). Blood chemistry in the PNX subgroup compared to patients without PNX showed a significant increase in LDH (420 U/L vs 345 U/L, respectively p = 0.003), ferritin (1111 mg/dl vs 660 mg/dl, respectively p = 0.006) and decreased lymphocytes (HR: 4.440, p = 0.004). PNX may be associated with a worse prognosis in terms of mortality in COVID patients. Possible mechanisms may include the hyperinflammatory status associated with critical illness, the use of NIV, the severity of respiratory failure and cognitive impairment. We suggest, in selected patients showing low P/F ratio, cognitive impairment and metabolic cytokine storm, an early treatment of systemic inflammation in association with high-flow oxygen therapy as a safer alternative to NIV in order to avoid fatalities connected with PNX.

Spontaneous pneumothorax and COVID-19: Precipitants to a complex HIV-AIDS diagnosis

A 48-year-old male presented with spontaneous pneumothorax requiring chest tube placement in the setting of COVID-19 infection. CT chest revealed bilateral ground-glass opacities and multiple, large, gas-filled, cavitary lesions in the lungs bilaterally. These imaging findings led to an initial HIV diagnosis with the patient presenting at a CD4+ count of <32 cells/µL. He was found to additionally have infections with Mycobacterium kansasii, cytomegalovirus, Pneumocystis jirovecii, and Candida albicans. After developing worsening hypoxic respiratory failure, he developed additional pneumothoraces bilaterally, requiring repeated chest tube placement. He was treated with antimicrobial therapy for his underlying infections and subsequently started on combined antiretroviral therapy.

"Pneumomediastinum: A marker of severity in Covid-19 disease"

Objective

The goal of this study was to look at the incidence, risk factors, clinical characteristics, and radiological aspects of COVID-19 patients who developed pneumomediastinum and compare these features between those who died and those who survived.

Materials and methods

This retrospective observational study included COVID-19 patients having pneumomediastinum on CT from May 2020 to May 2021 in a COVID-19 care hospital. 1st wave patients were considered between the period of May 2020 to January 2021 and those in the second wave between February 2021 to May 2021. The clinical details were analyzed by a consultant intensivist and CT scans were read by a team of 6 resident radiologists and 5 experienced radiologists. Demographic data, co-morbidities, clinical parameters, hemodynamic markers, radiological involvement and associated complications were analyzed.

Results

During the study period, 10,605 COVID-19 patients were admitted to our hospital of which 5689 underwent CT scan. 66 patients were detected to have pneumomediastinum on CT; 26 of them in the first wave and 40 in the second wave. Out of 66, 28 patients were admitted to ICU, 9 during the first wave and 18 during the second wave. The overall incidence of developing pneumomediastinum was 1.16%. Incidence in the 1st wave was 1.0% and in the 2nd wave was 1.29%. The overall mortality rate in admitted COVID-19 patients was 12.83% while it was 43.9% in COVID-19 patients who developed pneumomediastinum. Incidence of pneumomediastinum and pneumothorax was high in patients with extensive parenchymal involvement. 59/66 (89%) cases of pneumomediastinum had severe CT score on imaging.

Conclusion

We conclude that pneumomediastinum is a marker of poor prognosis. Timely diagnosis of interstitial emphysema or pneumomediastinum will aid in planning early protective ventilation strategies and timely intervention of complications.

The Effects of Endotracheal Tube Size During Bronchoscopy in Simulated Models of Intubated Patients

OBJECTIVE

The aim is to use a simulation lung model to assess the possibility of performing bronchoscopy through endotracheal tubes (ETT) less than 8.0-mm while appropriately ventilating patients with normal and ARDS lungs in the setting of SARS-CoV-2.

METHODS

Five SHERIDAN® ETTs were used to ventilate SimMan® 3G under respiratory compliance levels representing normal and severe ARDS lungs. Baseline measurements of peak pressure, plateau pressure, and auto-positive end expiratory pressure (auto-PEEP) were recorded at four different inspiratory times (Ti). Three different-sized disposable bronchoscopes were inserted, and all measurements were repeated.

RESULTS

Normal lung model: Slim bronchoscopes in 6.0-mm ETTs resulted in plateau pressures <30 cm H₂ O, and increasing Ti to minimize peak pressure resulted in low auto-PEEP. Regular bronchoscopes in 7.0-mm ETTs had similar results. Large bronchoscopes in 7.5-mm ETTs generated plateau pressures ranging from 28 to 35 cm H₂ O with modest auto-PEEP. Severe ARDS lung model: Slim bronchoscopes in 6.0-mm ETTs resulted in plateau pressures of 46 and an auto-PEEP of 5 cm H₂ O. Regular bronchoscopes in 7.0-mm ETTs generated similar results. Large bronchoscopes in 8.0-mm ETTs displayed plateau pressures of 44 and an auto-PEEP of 2 cm H₂ O.

CONCLUSION

To mitigate risk of laryngeal injury, larger ETTs during bronchoscopy should be avoided. Our data show bronchoscopy with any ETT causes auto-PEEP and high plateau pressures, especially in lungs with poor compliance; however, ETT less than 7.5 mm can be used when considering several factors. Our data also suggest similar studies in patients with varying degrees of ARDS would be informative.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:147-153, 2023.

Case of Spontaneous Pneumothorax After Recent COVID Pneumonia Hospitalization

An elderly man with COPD and heart failure was admitted to the Family Medicine Inpatient Service from the Emergency Department (ED) after experiencing acute onset of shortness of breath at home. He had recently been briefly hospitalized with COVID pneumonia. Upon arrival in the ED, he was requiring continuous positive airway pressure to maintain oxygen saturations. Overall, physical exam was notable for mild respiratory distress. Lab evaluation was unremarkable, but chest x-ray showed a right sided pneumothorax. Spontaneous pneumothoraces have been described in post-COVID cases, with COPD and mechanical ventilation thought to be risk factors. Treatment consists of supportive cares, needle decompression and thoracostomy if necessary. Providers should be aware of this rare albeit serious complication and monitor higher risk patients appropriately.

Retrospective analysis of COVID-19 patients developing otherwise rare complications

Background

Over the last 2 years, it has been felt that there was a disproportionate incidence of complications including pneumothorax, pneumomediastinum, and renal disease necessitating dialysis in patients with COVID-19 as compared to patients without COVID-19.

Methods

In a retrospective cohort, all patients were admitted to St. Joseph Mercy Oakland Hospital in Pontiac, Michigan, between March 2020 and November 2021. The data collected included age, sex, BMI, length of stay, COVID-19 PCR result, diagnosis of pneumothorax, diagnosis of pneumomediastinum, diagnosis of renal failure, orders for dialysis, and orders for mechanical ventilation.

Results

Nine thousand five hundred twenty-two patients are included in this study, with 35.6% (3,392 patients) COVID-19 suspected or confirmed positive and 64.4% (6130 patients) confirmed COVID-19 negative. There were 29 cases of pneumomediastinum and 24 cases of pneumothorax, none of which occurred in intubated patients. The incidence of pneumomediastinum (p = 0.001), CODE BLUE (p = 0.01), and mechanical ventilation (p = 0.001) was significantly higher in the COVID-19 positive/suspected group. There was no significant difference in incidence of pneumothorax (p = 0.294). The incidence of dialysis was significantly higher (p < 0.0001) in the COVID-19 negative group.

Conclusions

In review of prior literature and proposed mechanisms, we believe that it was possibly the damage that SARS-CoV-2 inflicts upon lung parenchyma that led to the increased incidence of pneumomediastinum. Given our mixed findings of incidences of pneumomediastinum, pneumothorax, and dialysis, our hope is to remain vigilant to uncover further disease associations and/or complications as more COVID-19 case data becomes available.

Coronavirus disease tracheostomy complications: a scoping review

BACKGROUND

Coronavirus disease 2019 increased the numbers of patients requiring prolonged mechanical ventilation, with a subsequent increase in tracheostomy procedures. Coronavirus disease 2019 patients are high risk for surgical complications. This review examines open surgical and percutaneous tracheostomy complications in coronavirus disease 2019 patients.

METHODS

Medline and Embase databases were searched (November 2021), and the abstracts of relevant articles were screened. Data were collected regarding tracheostomy technique and complications. Complication rates were compared between percutaneous and open surgical tracheostomy.

RESULTS

Percutaneous tracheostomy was higher risk for bleeding, pneumothorax and false passage. Surgical tracheostomy was higher risk for peri-operative hypoxia. The most common complication for both techniques was post-operative bleeding.

CONCLUSION

Coronavirus disease 2019 patients undergoing tracheostomy are at higher risk of bleeding and peri-operative hypoxia than non-coronavirus disease patients. High doses of anti-coagulants may partially explain this. Reasons for higher bleeding risk in percutaneous over open surgical technique remain unclear. Further research is required to determine the causes of differences found and to establish mitigating strategies.

THE EFFECT OF COVID-19 VACCINES ON PNEUMOTHORAX IN GERIATRIC PATIENTS HOSPİTALIZED IN INTENSIVE CARE UNIT DUE TO COVID-19

In our study, we examined the effect of COVID-19 vaccination on the incidence of pneumothorax in intensive care patients over age 65. COVID-19 intensive care patients that presented to our department between April 2020 and May 2021 during the COVID-19 pandemic were evaluated retrospectively. Patients were divided into two main groups, i.e., before and after the vaccination period. Patients were evaluated retrospectively for the following parameters: gender, age, side of pneumothorax, mortality, discharge, comorbidity, and additional pleural complications. The total number of patients was 87, i.e., 66 patients before vaccination and 21 patients after vaccination. When patients in the pre- and post-vaccination period were compared, there was a significant difference in the incidence of pneumothorax between the two groups (p<0.05). Pneumothorax was less common after vaccination. When patients with pneumothorax and tube thoracostomy were evaluated according to pre- and post-vaccination mortality, mortality was significantly higher (89%) in the pre-vaccination period (p<0.05). We consider that COVID-19 vaccines used in patients aged over 65 reduced the incidence of pleural complications, especially pneumothorax. We think that mortality due to pneumothorax in patients over 65 years of age was lower during the vaccination period. In addition, we think that bilateral pneumothorax was more common in the non-vaccinated period. As a result, we think that life-threatening pneumothorax and similar complications could be reduced by increasing the number of vaccines made in the COVID-19 pandemic and spreading it around the world.

Community-Acquired Pneumonia: Postpandemic, Not Post-COVID-19

The coronavirus disease 2019 (COVID-19) pandemic upended our approach to imaging community-acquired pneumonia, and this will alter our diagnostic algorithms for years to come. In light of these changes, it is worthwhile to consider several postpandemic scenarios of community-acquired pneumonia: (1) patient with pneumonia and recent positive COVID-19 testing; (2) patient with air space opacities and history of prior COVID-19 pneumonia (weeks earlier); (3) multifocal pneumonia with negative or unknown COVID-19 status; and (4) lobar or sublobar pneumonia with negative or unknown COVID-19 status. In the setting of positive COVID-19 testing and typical radiologic findings, the diagnosis of COVID-19 pneumonia is generally secure. The diagnosis prompts vigilance for thromboembolic disease acutely and, in severely ill patients, for invasive fungal disease. Persistent or recurrent air space opacities following COVID-19 infection may more often represent organizing pneumonia than secondary infection. When COVID-19 status is unknown or negative, widespread airway-centric disease suggests infection with mycoplasma, Haemophilus influenzae, or several respiratory viruses. Necrotizing pneumonia favors infection with pneumococcus, Staphylococcus, Klebsiella, and anaerobes. Lobar or sublobar pneumonia will continue to suggest the diagnosis of pneumococcus or consideration of other pathogens in the setting of local outbreaks. A positive COVID-19 test accompanied by these imaging patterns may suggest coinfection with one of the above pathogens, or when the prevalence of COVID-19 is very low, a false positive COVID-19 test. Clinicians may still proceed with testing for COVID-19 when radiologic patterns are atypical for COVID-19, dependent on the patient's exposure history and the local epidemiology of the virus.

Pneumothorax/pneumomediastinum and pre-existing lung pathology in ventilated COVID-19 patients: a cohort study

Background

There is an increasing number of reports on developing pneumothorax/pneumomediastinum among severe acute respiratory syndrome coronavirus disease 2019 (SARS-COVID-19) patients. The aim of our study was whether pre-existing diffuse lung pathology increases visceral pleural vulnerability resulting in pneumomediastinum and pneumothorax among mechanically ventilated COVID-19 patients?

Methods

A total of 138 consecutive COVID-19 patients admitted to the Intensive Care Unit of Petz Aladár University Teaching Hospital between 1st March 2020 and 1st February 2021 were included. Sixty/138 (43.48%) patients had one or more computer tomography scans of the chest. Analysis was focused on the image defined lung conditions during artificial ventilation.

Results

Thirteen out of 60 ventilated patients developed pneumothorax or pneumomediastinum proven by computer tomography (9.42%). Three/13 patients suffered from pre-existing lung parenchyma pathology, while 10/13 had only COVID-19 infection-related image abnormality. Forty-three/60 patient had healthy lung pre-COVID. Kruskal-Wallis test, Spearman correlation and Cox regression calculations did not reveal any statistically significant result proving increased vulnerability during pressure support therapy and visceral pleural breakdown in patients with pre-existing lung pathologies.

Conclusions

Pre-existing lung pathology does not increase the risk of onset of pneumothorax or pneumomediastinum in comparation with previously healthy lungs of ventilated COVID-19 patients.

Pneumothorax in Critically Ill COVID-19 Patients: Prevalence, Analysis of Risk Factors and Clinical Outcomes

BACKGROUND

Previous studies have been conducted to assess pneumothorax. However, few studies were done to assess pneumothorax in COVID-19 patients in the intensive care unit (ICU).

OBJECTIVE

Our aim is to describe and analyze the prevalence, clinical characteristics, risk factors, and outcomes of COVID-19 pneumothorax patients in the intensive care unit.

METHODS

We performed a retrospective review of the medical records of 418 patients, who tested positive for COVID-19 by polymerase chain reaction test and required ICU admission in King Fahad Hospital of The University from 02/01/2020 to 01/09/2021. A total number of 36 pneumothorax patients were included in the study.

RESULTS

Of 418 patients who were followed up in the intensive care unit as COVID-19 cases, 36 patients developed a pneumothorax (8.61%). The mean age of the patients was 55.6 ± 15.06 years, 23 patients were male, and 13 were female. Seventeen patients were obese, and only one patient was an active smoker. Twenty-four patients had at least one comorbidity; hypertension was the most common. Thirty-two patients were intubated, and the duration of intubation was 23.23 ±15.9 days. The time from intubation to pneumothorax development was 8.8 ± 9.3 days. Six patients were on bilevel positive airway pressure ventilation (BIPAP), 2 patients on continuous positive airway pressure ventilation (CPAP), 3 patients on High-Flow Nasal Cannula ventilation (HFNC), 9 patients on pressure-control ventilation (PC), and 16 patients on pressure regulated volume control ventilation (PRVC). Of 36 patients, 26 died, and the mortality rate was 72.2%.

CONCLUSION

Our study showed that risk factors of pneumothorax occurrence in COVID-19 critically ill patients include male patients, hypertension, diabetes mellitus, endotracheal intubation and mechanical ventilation. More efforts should be made to determine the risk factors and assess the outcomes of those patients to develop preventive measures and management guidelines.

Evaluation of the Prevalence of Barotrauma and Affecting Factors in Patients with COVID-19 during Follow-Up in the Intermediate Care Unit

It is known that pneumothorax (PX) and pneumomediastinum (PM) develop due to COVID-19 disease. The objective of our study was to determine the prevalence of PX/PM due to COVID-19 in the intermediate intensive care unit (IMCU) and to evaluate the factors causing barotrauma and also the clinical outcomes of these patients. A total of 283 non-intubated patients with COVID-19 pneumonia followed up in the IMCU in a 1-year period were included in the study. The patients were classified as group 1 (having barotrauma) and group 2 (without barotrauma). The rate of barotrauma was 8.1% (n = 23, group 1). PX developed on the right hemithorax in 12 (70.6%) patients. Group 1 had statistically significantly higher 28-day mortality rates compared with group 2 (p = 0.014). The eosinophil and d-dimer levels of the patients in group 1 were higher, while C-reactive protein (CRP), fibrinogen, and albumin levels were lower than Group 2 (p < 0.001, p = 0.017, p = 0.001, p < 0.001), and p < 0.001, respectively). The similar rates of NIMV administration in our study groups support that barotrauma is not the only mechanism in the development of PX/PM. The findings of high blood eosinophil count and low blood levels of CRP, albumin, and fibrinogen in the barotrauma group of our study might be a pathfinder for future studies.

Pneumothorax in Intubated Patients With COVID-19: A Case Series

Pneumothorax is a rare complication among mechanically ventilated patients since low tidal volumes are used nowadays instead of traditional high tidal volumes, but the incidence is slightly higher in patients with high positive end-expiratory pressure (PEEP). Herein we describe a case series of nine patients who were on mechanical ventilation due to acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) and developed pneumothorax in due course. A retrospective analysis was done on COVID-19 intubated patients from March 2020 to June 2020 in a community hospital in Central New Jersey, which was one of the early hit states in the United States at the beginning of the pandemic. Outcomes were studied. The demographics of patients like age, gender, and body mass index (BMI); risk factors like smoking, comorbidities especially chronic lung disease, and the treatment they received were compared. We compared the total number of days on the ventilator, the highest PEEP they received, and the ventilator day when pneumothorax developed. All the patients who developed pneumothorax had a chest tube inserted to treat it. The mortality was noted to be 100% indicating that pneumothorax is a life-threatening complication of COVID-19 and COVID-19 by itself is a risk factor for pneumothorax likely due to a change in lung mechanics. There is a need for large-scale studies to confirm that these outcomes are related to COVID-19.

Fatal Pyopneumothorax in a COVID-19 Patient

The COVID-19 pandemic has impacted every aspect of our lives since its start in December 2019. Among various COVID-19 complications, pleural complications are also increasingly reported but rarely from Nepal. Here, we presented a case of pyopneumothorax in a 52-year-old male patient referred from another center and admitted to the ICU of Nepal Armed Police Force Hospital with a diagnosis of severe COVID-19 pneumonia in the background of alcohol withdrawal syndrome with delirium tremens and generalized tonic-clonic seizures. He developed a rapid decline in respiratory status with a right-sided pneumothorax and underwent an immediate needle thoracostomy, followed by chest tube insertion. On the sixth day of admission, he had thick yellowish pus in the chest drain (pyopneumothorax), and despite the rigorous efforts in treatment, he died on the 15th day of admission. Though relatively uncommon, clinicians should consider pleural complications like pneumothorax, pleural effusion, pneumomediastinum, and empyema in patients with impaired immune status. In such patients, we should ensure prompt diagnosis with the earliest intervention and rationale use of antibiotics.

Demographic comparison of the first, second and third waves of COVID-19 in a tertiary care hospital at Jaipur, India

Background

Coronavirus disease 2019 (COVID-19) infection in India demonstrated three peaks in India, with differences in presentation and outcome in all the three waves. The aim of the paper was to assess differences in the epidemiological, clinical features and outcomes of patients with COVID-19 presenting at a tertiary care hospital in the three waves at Jaipur, India.

Methods

This was a retrospective study conducted at a tertiary care hospital at Jaipur, India. Demographic, clinical features and outcomes were compared of confirmed COVID-19 cases admitted during the first wave (16-7-2020 to 31-1-2021), second wave (16-3-2021 to 6-5-2021) and third wave (1-1-22 to 20-2-22) of the outbreak.

Results

There were 1006 cases, 639 cases and 125 cases admitted during the three waves, respectively. The cases presenting in the second wave were significantly younger, with significantly higher prevalence of symptoms such as fever, cough, sore throat, nausea, vomiting, headache, muscle ache, loss of appetite and fatigue (P < 0.05). A significantly higher proportion of patients received Remdesivir in the second wave (P < 0.001). However, in the second wave, the use of low molecular weight heparin, plasma therapy, non-invasive and invasive ventilator were higher (P < 0.001). Co-morbid conditions were significantly higher in the admitted patients during the third wave (P < 0.05). Radiological scores were similar in second and third wave, significantly higher than the first wave. Lymphopenia and rise of inflammatory markers including C-reactive protein and interleukin-6 were more evident in the second wave (P < 0.001). The mean mortality, hospital stay and air-leak complications were also significantly higher in the second wave (P < 0.001).

Conclusions

The second wave was more vicious in terms of symptoms, inflammatory markers, radiology, complications, requirement of ventilation and mortality. Mutation in the virus, lack of immunity and vaccination at the time point of second wave could have been the possible causes. The ferocity of the second wave has important implications for the government to formulate task forces for effective management of such pandemics.

An Intelligent Sensor Based Decision Support System for Diagnosing Pulmonary Ailment through Standardized Chest X-ray Scans

Academics and the health community are paying much attention to developing smart remote patient monitoring, sensors, and healthcare technology. For the analysis of medical scans, various studies integrate sophisticated deep learning strategies. A smart monitoring system is needed as a proactive diagnostic solution that may be employed in an epidemiological scenario such as COVID-19. Consequently, this work offers an intelligent medicare system that is an IoT-empowered, deep learning-based decision support system (DSS) for the automated detection and categorization of infectious diseases (COVID-19 and pneumothorax). The proposed DSS system was evaluated using three independent standard-based chest X-ray scans. The suggested DSS predictor has been used to identify and classify areas on whole X-ray scans with abnormalities thought to be attributable to COVID-19, reaching an identification and classification accuracy rate of 89.58% for normal images and 89.13% for COVID-19 and pneumothorax. With the suggested DSS system, a judgment depending on individual chest X-ray scans may be made in approximately 0.01 s. As a result, the DSS system described in this study can forecast at a pace of 95 frames per second (FPS) for both models, which is near to real-time.

Clinical characteristics and laboratory parameters associated with the risk of severe COVID-19 in patients from two hospitals in Northeast Brazil

Background:

Although most coronavirus disease 2019 (COVID-19) infections are mild, some patients have severe clinical conditions requiring hospitalization. Data on the severity of COVID-19 in Brazil are scarce and are limited to public databases. This study aimed to investigate the clinical and laboratory factors associated with the severity of COVID-19 in a cohort of hospitalized adults from two hospitals in Northeast Brazil.

Methods:

Patients over 18 years of age who were hospitalized between August 2020 and July 2021 with a confirmed diagnosis of COVID-19 were included. The patients were classified into two groups: moderate and severe. Clinical, laboratory and imaging parameters were collected and compared between the groups. A multivariate logistic regression model was used to determine the predictors of COVID-19 severity.

Results:

This study included 495 patients (253 moderate and 242 severe). A total of 372 patients (75.2%) were between 18 and 65 years of age, and the majority were male (60.6%; n = 300). Patients with severe disease had higher levels of leukocytes, neutrophils, platelets, neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, blood glucose, C-reactive protein, ferritin, D-dimer, aspartate aminotransferase, creatinine, and urea (p < 0.05). In multivariate logistic regression, the following variables were significant predictors of COVID-19 severity: leukocytes (odds ratio [OR] 3.27; 95% confidence interval [CI] 2.12-5.06), international normalized ratio (INR) (OR 0.22, 95% CI 0.14-0.33), and urea (OR 4.03; 95% CI 2.21-7.35).

Conclusions:

The present study identified the clinical and laboratory factors associated with the severity of COVID-19 in hospitalized Brazilian individuals.

Incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema in COVID-19

Objective

The coronavirus disease 2019 (COVID-19) pandemic reached New York City in March 2020, leading to a state of emergency that affected many lives. Patients who contracted the disease presented with different phenotypes. Multiple reports have described the findings of computed tomography scans of these patients, several with pneumothoraces, pneumomediastinum, and subcutaneous emphysema. Our aim was to describe the incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema related to COVID-19 found on radiologic imaging.

Methods

A retrospective chart review was conducted of all confirmed COVID-19 patients admitted between early March and mid-May to two hospitals in New York City. Patient demographics, radiological imaging, and clinical courses were documented.

Results

Between early March and mid-May, a total of 1866 patients were diagnosed with COVID-19 in the two hospitals included in the study, of which 386 were intubated. The majority of these patients were men (1090, 58.4%). The distribution of comorbidities included the following: hypertension (1006, 53.9%), diabetes (544, 29.6%), and underlying lung disease (376, 20.6%). Among the 386 intubated patients, 65 developed study-specific complications, for an overall incidence of 16.8%; 36 developed a pneumothorax, 2 developed pneumomediastinum, 1 had subcutaneous emphysema, and 26 had a combination of both. The mean time of invasive ventilation was 14 days (0-46, interquartile range = 6-19, median 11). The average of highest positive end expiratory pressure within 72 h of study complication was 11 (5-24) cmH20. The average of the highest peak inspiratory pressure within 72 h of complication was 35.3 (17-52) cmH2O. In non-Intubated patients, 9/1480 had spontaneous pneumothorax, for an overall incidence of 0.61 %.

Conclusion

Intubated patients with COVID-19 pneumonia are at high risk of pneumothorax, pneumomediastinum, and subcutaneous emphysema. These should be considered in differential diagnosis of shortness of breath or hypoxia in a patient with a new diagnosis of COVID-19 or worsening hemodynamics or respiratory failure in an intensive care unit setting.

Diagnostic and Therapeutic Characteristics in Patients with Pneumotorax Associated with COVID-19 versus Non-COVID-19 Pneumotorax

Introduction: Pneumothorax is a condition that usually occurs in thin, young people, especially in smokers. It is an unusual complication of COVID-19 disease that can be associated with worse results. This disease can occur without pre-existing lung disease or without mechanical ventilation. Materials and Methods: We present a monocentric comparative retrospective study of diagnostic and treatment analysis of two groups of patients diagnosed with COVID-19 and non-COVID-19 pneumothorax. All patients included in this study underwent surgery in a thoracic surgery department. The study was conducted over a period of 18 months. It included 34 patients with COVID-19 pneumothorax and 42 patients with non-COVID-19 pneumothorax. Results: The clinical symptoms were more intense in patients with COVID-19 pneumothorax. We found that the patients with COVID-19 had significantly more respiratory comorbidities. Diagnostic procedures include chest CT exam for both groups. Laboratory findings showed that increasing values for the analyzed data were consistent with the deterioration of the general condition and the appearance of pneumothorax in the COVID-19 group. The therapeutic attitude regarding the non-COVID-19 group was to eliminate the air from the pleural cavity and surgical approach to the lesion that determined the occurrence of pneumothorax. The group of patients with COVID-19 pneumothorax received systemic treatment, and only minimal pleurotomy was performed. The surgical approach did not alter patients’ survival. Conclusions: Careful monitoring of the patient’s clinic and laboratory tests evaluating the degradation of the lung parenchyma, correlated with the imaging examination (chest CT) is mandatory and reduces COVID-19 complications. Early imaging examination starts an effective diagnosis and treatment management. In severe COVID-19 pneumothorax cases, the pneumothorax did not influence the evolution of COVID-19 disease. When we found that the general condition worsened with the rapid progression of dyspnea and the deterioration of the general condition, and we found that it represented the progression or recurrence of pneumothorax.