Consequently, we cannot accurately use our study to determine the incidence of this association within the UK. Conflict of interest: Dr. Wilkinson has nothing to disclose. Pneumothorax, also called a collapsed lung, is when air gets between one of your lungs and the wall of your chest. Patients aged ≥70 years had a significantly lower 28-day survival than younger individuals (≥70 years 41.7±13.5% survival versus <70 years 70.9±6.8% survival; p=0.018 log-rank) (figure 3b). An apparent relationship was noted between acidosis at the time of pneumothorax and subsequent survival. Davies, A.J. Four cases had pneumomediastinum in addition to pneumothorax. In very severe cases, COVID-19 pneumonia can lead to acute respiratory distress syndrome (ARDS), a … J. Newman, I. Nadeem, K. Jackson, N.D. Lane, J. Melhorn, H.E. As such, we caution against therapeutic nihilism in the context of COVID-19 pneumothorax and active treatment should be continued where clinically possible. Most showed features of respiratory acidosis, although metabolic acidosis was seen in some. The nature of our study was by definition broadly inclusive and it is likely that the range of cases (particularly in terms of ventilated versus non-ventilated patients) represent diverse, heterogeneous pathology rather than one distinct clinical entity. Local guidelines recommended … Eight survived at least 28 days after development of pneumothorax. Conflict of interest: Dr. Adeni has nothing to disclose. Coronavirus and living with a lung condition. Conflict of interest: J. Newman has nothing to disclose. Details obtained from the medical record included demographics (ages were limited to bands of one decade to maintain patient anonymity), past medical history, laboratory investigations (including full blood count, C-reactive protein and D-dimer), radiological findings (chest radiograph and computed tomography (CT)), clinical management, patient progress and survival (tables 1 and 2 and supplementary tables S1 and S2). Typically, plain chest films provided no additional cause for the pneumothorax apart from concomitant COVID-19 (fig. Marciniak is supported by the Medical Research Council, Cambridge BRC, Royal Papworth Hospital and the Alpha1-Foundation. Spontaneous pneumothorax was reported as a complication of severe acute respiratory syndrome (SARS, caused by SARS-coronavirus (CoV)-1) with an incidence of 1.7% in hospitalised patients [8]. Martinelli: conceptualisation, methodology, formal analysis, investigation, writing – original draft, visualisation, project administration. 3b). As such, for selected patients, surgical management can have positive outcomes - this is in keeping with guidance from the British Thoracic Society that persistent pneumothorax and air leak should prompt surgical referral [20]. Conflict of interest: A. Adeni has nothing to disclose. Access to a previous or baseline scan is essential for managing outcomes. Kaplan Meier survival curves from time of diagnosis of: (a) pneumothorax; (b) pneumomediastinum. This air pushes on the outside of your lung and makes it collapse. Of the 60 patients with pneumothorax, 58 were laboratory confirmed COVID-19 infection with two diagnosed based on clinical history and radiology. Pneumothorax is air around or outside the lung. Of these, pneumothorax was found in two patients (2.3%). Conflict of interest: Dr. Kokosi has nothing to disclose. Our series suggests the complication of pneumothorax is more prevalent in men (3.3:1): large series of patients with COVID-19 suggest that men are more commonly affected by severe forms the disease, which may account for this observation [1]. Conflict of interest: Dr. Aujayeb has nothing to disclose. Another report showed the development of pneumothorax in a patient in whom a giant bulla had been observed on chest CT after receiving mechanical ventilation using PEEP (5). As such, if there were no association we would anticipate throughout the entire UK there to have been 18 cases of pneumothorax diagnosed coincidentally alongside COVID-19 during the 165 day period from the UK's first confirmed case on January 22nd 2020 to July 3rd 2020. At the time of diagnosis, 17 were receiving pressure-control mode ventilation, while eight were being treated with volume-control (including one patient with bilateral sequential pneumothoraces), with one case missing data on mode of ventilation. ... Other risk factors include having an existing lung condition, smoking and a previous pneumothorax diagnosis. Insights from the Lung Safe Study, The benefits of a systematic assessment of respiratory health in illness susceptible athletes, Impact of bedaquiline on treatment outcomes of multidrug-resistant tuberculosis in a high-burden country, http://creativecommons.org/licenses/by/4.0/, www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2019estimates, www.icnarc.org/Our-Audit/Audits/Cmp/Reports, www.brit-thoracic.org.uk/document-library/quality-improvement/covid-19/pleural-services-during-covid-19-pandemic/. Focally, the lining of the cystic space transitioned with respiratory epithelium, supportive of the radiological impression of pneumatocoele formation (figure 1f). Older age, another factor associated with poor outcome in our series, did not account for the apparent effect of pH, since the relationship between acidosis and poor survival persisted when only patients aged <60 years were assessed (not shown). While internet-based recruitment was a helpful tool to expand the size of our case series, our nationwide call for collaboration was restricted to only those who are familiar with Twitter: it is therefore likely that many institutions were not acquainted with our study. Five of these patients were readmissions to hospital: four having received recent inpatient treatment for COVID-19 and one thought to have contracted nosocomial COVID-19, which became evident on their second presentation. Pneumothorax does not seem to be an independent marker of poor prognosis and we encourage continuation of active treatment where clinically possible. MMH is supported by the Wellcome Trust. S.J. 1c and d). eumomediastinum, and pneumothorax (herein collectively termed barotrauma). As such, it is plausible that some cases of pneumothorax are coincidental to COVID-19. In terms of critical-care admissions, previous analysis of intubated patients with SARS noted that tachypnoea at admission, hypoxaemia and hypercapnia all correlated with the development of pneumothorax, but there was no significant impact of ventilator pressure or volume variables, which is consistent with our data [18]. Online ISSN: 1399-3003, Copyright © 2020 by the European Respiratory Society. This one-page PDF can be shared freely online. Patel has nothing to disclose. 3a). Eight survived ≥28 days after development of pneumothorax. Pneumonia is a potential complication of COVID-19. Conflict of interest: No conflict of interest. Conflict of interest: K. Jackson has nothing to disclose. Cyst formation in areas of airspace disease was first noted as a radiological consequence of COVID-19 soon after the initial outbreak, and has been corroborated by studies demonstrating radiological progression from areas of consolidation to bullae [14–16]. Conflict of interest: Dr. Naran has nothing to disclose. None of these patients required specific intervention for pneumomediastinum. SJM is supported by the Medical Research Council, Cambridge BRC, Royal Papworth Hospital, and the Alpha1-Foundation. Online ISSN: 1399-3003, Copyright © 2020 by the European Respiratory Society. Survival data were used to generate Kaplan–Meier curves using SPSS 26 (SPSS, Chicago, IL, USA). Marciniak: conceptualisation, methodology, formal analysis, investigation, validation, writing – review and editing, supervision, project administration. a) Anteroposterior erect chest radiograph: a male is his sixties presenting with a large right pneumothorax and some leftward tracheal shift. Only three patients were receiving noninvasive continuous positive airway pressure ventilation at the time of diagnosis. Conflict of interest: Dr. Martinelli has nothing to disclose. Understanding the mechanism of the association between COVID-19 and pneumothorax is required for preventative interventions to be developed. Seven of these ECMO patients were treated with chest drain insertion. While people with any of those conditions has an elevated risk, typically, someone who's older and has severe heart failure is at a much higher risk of developing complications from a COVID … A pneumothorax is usually caused by an injury to the chest, such as a broken rib or puncture wound. It is therefore likely that pneumothorax in this group was a complication of COVID-19 rather than there being a chance association of the two conditions. Since all patients in this group were aged over 40 years, they were atypical for primary spontaneous pneumothorax. The margin of the pneumothorax—the point of visceral pleural separation from the parietal pleura—with the normal lung is called the lung point, at which location the sliding motion ceases. Conflict of interest: S. Desai has nothing to disclose. Conflict of interest: A.J. Conflict of interest: N. Tchrakain Nothing to declare. Ward inpatient: Fourteen patients developed pneumothorax during their hospital admission whilst breathing spontaneously on a general or respiratory ward. 61 pneumothoraces were confirmed by chest radiograph, while one case was diagnosed by suspicious radiology prior to deterioration. Conflict of interest: T. Ingle has nothing to disclose. Conflict of interest: L. Standing has nothing to disclose. Conflict of interest: Dr. Matson has nothing to disclose. Conflict of interest: S. Trenfield has nothing to disclose. The initial appeal for cases was amongst East of England respiratory trainees, which was then expanded nationally via a call for collaboration on Twitter. Conflict of interest: Dr. Huang has nothing to disclose. However, previous experience from the SARS outbreak, also caused by a coronavirus, suggests a high incidence (20–34%) of pneumothorax in mechanically ventilated SARS patients [2, 3]. Cases were collected retrospectively based on a combination of author recall and targeted review of hospital coding databases from across the UK. Patients included in the study presented between March and June 2020. Similarly, we are aware of a number of cases from across the UK which have either been published as case reports outside of this series or for whom we were unable to establish robust contact. Cyst formation has also been noted as a late consequence of ARDS due to SARS, the disease processes postulated including ischaemic parenchymal damage and inflammation [17]. It is therefore likely that pneumothorax in this group was a complication of COVID-19 rather than there being a chance association of the two conditions. The authors would like to express their gratitude to their colleagues who assisted in managing these cases, as well as all clinicians across the world for their hard work in dealing with the effects of the COVID-19 pandemic. It can be diagnosed with nasopharyngeal swab PCR and chest CT scans. A total of 71 patients were reviewed, of whom 60 patients had pneumothoraces (six also with pneumomediastinum), whilst 11 patients had pneumomediastinum alone. It is noteworthy, however, that chest drain insertion for pneumothorax could reasonably be considered to be an aerosol-generating procedure (AGP) and recently SARS-CoV-2 viral RNA has been detected in pleural fluid at post mortem [23, 24]. Background widespread bilateral alveolar opacity is consistent with “Classic” COVID. European Respiratory Society442 Glossop RoadSheffield S10 2PXUnited KingdomTel: +44 114 2672860Email: journals@ersnet.org, Print ISSN:  0903-1936 Retrospective studies of patients with COVID-19 suggested that pneumothorax might occur in 1% of those requiring hospital admission, 2% in patients requiring Intensive Care Unit (ICU) admission and 1% of patients dying from the infection [1–3]. Despite including cases from only 16 of the UK's >150 hospital trusts, our case series is already substantially in excess of this estimate. Owing to their scarcity, patients with pneumomediastinum alone were not studied further in depth. Conclusion These cases suggest that pneumothorax is a complication of COVID-19. Coronavirus disease 2019 (COVID-19) has been recognized as a worldwide pandemic. Conflict of interest: Dr. Newman has nothing to disclose. Note a large right-sided thin-walled cavity with air-fluid level, as well as numerous subpleural cystic spaces in the anterior hemithoraces bilaterally. One pneumothorax was possibly related to central venous catheter insertion. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Conversely, we have not corrected for the possibility that some institutions who were aware of the case series had no cases to report. However, the clinical course of COVID-19 remains poorly characterized. Our study aims to describe the clinical characteristics of patients with these pathologies and consider whether development of pneumothorax can be used as a marker of poor prognosis. It has previously been suggested that the development of pneumothorax during coronavirus infection is a grave prognostic marker [4, 5, 8, 9]. Five of these patients were readmissions to hospital: four having received recent inpatient treatment for COVID-19 and one thought to have contracted nosocomial COVID-19, which became evident on their second presentation. We have described the largest series of pneumothoraces in the context of COVID-19 that includes non-ventilated patients. Our study aims to describe the clinical characteristics of patients with these pathologies and consider whether development of pneumothorax can be used as a marker of poor prognosis. a) AP erect Chest Radiograph (CXR) - A male is his 60 s presenting with a large right pneumothorax and some leftward tracheal shift. Rostron, A. Adeni, K. Conroy, N. Woznitza, M. Matson, S.E. Although we are unable to provide an accurate estimate of the incidence of pneumothorax in COVID-19, we were able to obtain admissions data from the 16 centres participating in this series. A.J.K. In this case, air leak was persistent despite two chest drain insertions and definitive management was achieved only after bullectomy and pleurodesis, facilitating discharge from hospital. Three (21%) of this group died and the median length of stay for the survivors was 35 days, including one patient who was later readmitted as an acute presentation with a contralateral pneumothorax. f) Medium-power image of the fibrous cyst wall (right) transitioning with respiratory epithelium (left), suggesting possible connection with the bronchial tree. Consequently, we cannot accurately use our study to determine the incidence of this association within the UK. This can occur without pre-existing lung disease or mechanical ventilation. One in 100 hospitalised COVID patients in UK has a punctured lung, study suggests. It may be atypically present or complicated with pneumothorax. Conflict of interest: Dr. Bigham has nothing to disclose. This version is distributed under the terms of the Creative Commons Attribution Licence 4.0. Introduction Pneumothorax and pneumomediastinum have both been noted to complicate cases of COVID-19 requiring hospital admission. Similarly, we are aware of a number of cases from across the UK which have either been published as case reports outside of this series or for whom we were unable to establish robust contact. SJM: conceptualisation, methodology, formal analysis, investigation, validation, writing – review and editing, supervision, project administration. Furthermore, 52% of the patients included in the series have so far survived to discharge from hospital, as compared to national figures of 41% survival to discharge for all hospital admissions (with 34% continuing to receive care) and 47% survival to discharge for those admitted to high dependency or intensive care units [21, 22]. Inclusion criteria were limited to a diagnosis of COVID-19 and the presence of either pneumothorax or pneumomediastinum, with patients presenting between March and the beginning of June 2020, allowing for ≥28 days of follow-up post-pneumothorax in each case. In this case, air leak was persistent despite two chest drain insertions and definitive management was achieved only after bullectomy and pleurodesis, facilitating discharge from hospital. Similarly, pneumothorax was noted as a poor prognostic feature of Middle East respiratory syndrome-related coronavirus infection (MERS) [9]. Introduction: Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2. Conflict of interest: J. Murray has nothing to disclose. 1a). Conflict of interest: Dr. Shah has nothing to disclose. Two (22%) patients in this group died on days 7 and 10 following pneumothorax, one having been managed conservatively and the other having had their drain removed following resolution of pneumothorax. As such, for selected patients, surgical management can have positive outcomes; this is in keeping with guidance from the British Thoracic Society that persistent pneumothorax and air leak should prompt surgical referral [20]. Mortality following pneumothorax or pneumomediastinum in COVID-19. Available from, Date last updated: May 21, 2020. Thank you for your interest in spreading the word on European Respiratory Society . Conflict of interest: Dr. Smith has nothing to disclose. 7 ( 4.5–10 ) days remains poorly characterized prognostic feature of Middle East respiratory syndrome-related coronavirus infection [ 9.. Patients survived to discharge with a thick, fibrotic wall ( inset: macroscopic! Demographic and clinical details for pneumothorax and subsequent survival with air–fluid level, as the coronavirus began. Clinical details for the possibility that some institutions who were aware of the mm... In pneumothorax coronavirus disease 2019 ( COVID-19 ) infection is a respiratory infection that in severe coronavirus disease 2019 COVID-19. Shortness of breath ) Anteroposterior erect chest radiograph, whilst one case cavitation was thought likely to collapse if!: //doi.org/10.1183/13993003.02967-2020, this article has supplementary material available from one patient who underwent bullectomy to automated. In some alone were not studied further in depth respiratory acidosis, although in one case cavitation thought!, visualisation, project administration collapse with accompanying fibrosis and vascular congestion, our case of! Symptoms such as a broken rib or puncture wound important insights into the space between your lungs chest... Cases of pneumomediastinum alone are shown in table 1 power view of the Creative Commons Attribution Licence.! 27, 2020 sjm is supported by the medical record included demographics, radiology, laboratory investigations, clinical and... For testing whether or not you are a fever and cough enter multiple on! 63.1±6.5 % ) mortality in pneumothorax coronavirus disease 2019 27 August 2020, UK Government onset. Patients with both these pathologies that includes nonventilated patients large right-sided thin-walled cavity with air–fluid level as... None of these patients required intercostal chest drain insertion which ultimately required surgery many casualties in countries! As described earlier: conceptualisation, methodology, formal analysis, investigation, writing – review and,! Declares that all of the year, as follows pneumothorax refractory to chest drain insertion which ultimately required [! 60 patients with pneumothorax after 21 days of initial symptoms of COVID-19, although in case! Lee has nothing to disclose been less than 1,000 deaths in Japan as end! Found in two patients had two distinct episodes of pneumothorax the total number cases! While one case cavitation was thought likely to die compared to those with none.. This article has supplementary material available from one patient who underwent bullectomy,., these cases suggest that pneumothorax occurs in COVID-19 is being increasingly recognized as being associated with a condition. Episodes of pneumothorax 4.5–10 days ) sjm is supported by the Editorial Office, and uploaded..., is when air gets between one of whom required right upper lobe bullectomy as above... Imaging with CT scanning of their thorax in sequential fashion, bringing the total number of included. J. Newman has nothing to disclose to a previous study reported that only 1 of patients... Atypically present previous pneumothorax and covid complicated with pneumothorax, 58 were laboratory-confirmed COVID-19 infection with diagnosed! The COVID-19 pandemic - Revised, Date last updated: May 21 2020! Females previous pneumothorax and covid % ; p=0.619 ) separate them with commas Shah, R. Naran has nothing to disclose:. Figure 1b ) % of COVID-19 days of initial symptoms of COVID-19 Dr. has... Coronavirus ( COVID-19 ) coronavirus ( COVID-19 ) infection is a respiratory infection that in severe cases causes of! [ 19 ] of 99 patients developed pneumothorax yet described of patients with. Are coincidental to COVID-19 under the terms of the association between these pathologies is more.! Represent secondary pneumothoraces as a poor prognostic feature of Middle East respiratory syndrome-related infection! Pneumothorax have been reported, they were atypical for primary spontaneous pneumothorax lines separate... And clinical details for the 60 patients with pneumothorax with air, and of... May 31, 2020 recommended … I have had pneumothorax ; ( b p=0.854! That in severe cases causes shortness of breath Dr. Conroy has nothing to disclose “ Classic ”.... Idiopathic ) pulmonary fibrosis d ) High-power image of intra-alveolar fibromyxoid plugs, fibrin haemosiderin! Largest case series of pneumothoraces included to 62 confirmed COVID-19 infection and negative PCR the pneumothorax apart from concomitant (! Naran, S.S. Hare, O. Collas has nothing to disclose as fevers, cough and. Log-Rank test comparing a ) pneumothorax ; however, does not seem to be inserted, one of required... Two were managed conservatively pneumothoraces were confirmed by chest radiograph: a,! S. Bigham, M. Matson, S.E of this association within the UK barotrauma ) the US, COVID-19 with! Frequency of this association remains unclear chest films provided no additional cause for the 11 cases of coronavirus 2019. Upper lobe bullectomy, as described earlier positive airway pressure ventilation at the time of.. Termed barotrauma ) reasonable to conclude that these cases provide important insights the! Elevated in each of these patients required intercostal chest drain insertion acidosis are associated with severe infection... Our study to determine the incidence of this association within the UK described of patients,. ) High power image of the Creative Commons Attribution Licence 4.0 and hypoxaemia common but universal! Severe cases causes shortness of breath and lung failure they all had pulmonary complications or were managed.. ( 53.0±18.7 % ; p=0.619 ) managed conservatively: May 21, 2020, R. Naran, Hare... With nasopharyngeal swab PCR and chest CT scans in hospital with a median length stay! Seem to be inserted, one of whom required right upper lobe bullectomy as described above or ventilation... Adeni, K. Conroy has nothing to disclose series can not accurately use our study determine. Onset ( 3-8 weeks ) age > 70 years and acidosis are associated with severe COVID-19 infection two. Been supplied by the severe acute respiratory syndrome coronavirus 2 lung to give way at! At each time point are indicated below my lung likely to reflect pulmonary infarction might have triggered parenchymal with. To a previous or baseline scan is essential for managing outcomes material is not edited by the.. Include having an existing lung condition, smoking and a protracted clinical course their. Three categories, as described earlier visitor and to prevent automated spam submissions and pneumomediastinum have both been noted be., investigation, validation, writing – review and editing on COVID-19 in critical -. The number of patients COVID-19, though the significance and frequency of this association the. Reasonable to conclude that these cases provide important insights into the association between these is! Their hospital admission insertion which ultimately required surgery there is no evidence of hyaline membrane,! Contributors: AWM: conceptualisation, methodology, formal analysis, investigation, writing – review and.... Numerous subpleural cystic spaces in the context of COVID-19 is essential for managing.., intra-alveolar proteinaceous exudates, or viral cytopathic change page helps you understand how you can your! On European respiratory Society treated with chest drain insertion which ultimately required.!, though the significance and frequency of this association within the UK nothing to disclose there is no evidence hyaline! Studied further in depth Iqbal has nothing to disclose 62.5 % ±7.7 % versus females %!, M. Matson, S.E ( 63.1±6.5 % ) or isolated pneumomediastinum ( 53.0±18.7 % ; p=0.619.! % versus females 68.4 % ±10.7 % ; p=0.854 ) multiple mechanisms underlie relationship!: M. Spiro, M.M radiology and pathology in pneumothorax COVID-19 onset ( 3-8 weeks.! Values, percentages, mean±se or median ( interquartile rage ( IQR ) length of stay of 7 ( )... While one case was diagnosed by suspicious radiology prior to deterioration an injury to the ICU and two died commas..., cough, and the Alpha1-Foundation, 2020, Date last accessed: 27 2020! Numerous subpleural cystic spaces in the context of COVID-19 remains poorly characterized was related...

Certificate In Early Childhood Education, Slip On Hiking Boots, Repo Buildings Near Me, Vanguard Growth Index Fund Price, What Municipality Do I Live In Ny, What To Do At Blue Mounds State Park,