Deniz Heppekcan 1, Egemen Ümit Hazar 2
Author affiliations:
Background & Objective: Coronavirus disease 2019 (COVID-19) claimed thousands of the lives during a limited period of time, but also enriched our scientific knowledge, especially regarding the respiratory pathogenesis and intensive care dynamics. This study was carried out to bridge the gap in the literature regarding the incidence, clinical features, and outcomes of spontaneous pneumothorax (SP) that develops during the course of COVID-19.
Methodology: The population of this single-center retrospective study consisted of all critically ill adult patients who tested positive for COVID-19, developed SP, and were admitted to the intensive care units (ICUs) of Acibadem University School of Medicine, Training and Research Hospital, between March 21, 2020 and May 31, 2021. Detailed medical records, clinical findings, chest computed tomography (CT) scans, and X-ray images of critically ill COVID-19 patients complicated by SP were obtained and analyzed.
Results: Of the 753 patients admitted to the ICUs during the study period, 600 tested positive for COVID-19 viral pneumonia. Of these patients, 549 met the diagnostic criteria for acute respiratory distress syndrome (ARDS), of whom 472 were treated with invasive mechanical ventilation (IMV) and 77 were treated without IMV. SP developed in a total of five (0.8%) patients, 4 (0.9%) of whom were on IMV support and 1 (1.2%) of whom was breathing spontaneously. Of these patients who developed SP, one patient on IMV support was female, and the remaining four were male. The median age of these five patients was 42 (33-64) years. Two (40%) of the five patients died in ICU.
Conclusion: The actual incidence of COVID-19-related spontaneous pneumothorax is yet to be elucidated and may require a large scale, multi-center study. COVID-19-related spontaneous pneumothorax is similar to ARDS-related spontaneous pneumothorax without COVID-19 in terms of clinical features and outcomes, its risk of occurrence is higher.
Abbreviations: COVID-19 - Coronavirus disease 2019; CT - computed tomography; IMV - invasive mechanical ventilation; SP - spontaneous pneumothorax
Keywords: SARS-Cov-2; COVID-19; Spontaneous Pneumothorax
Citation: Heppekcan D, Hazar EU. Spontaneous pneumothorax in critically ill patients with COVID-19. Anaesth. pain intensive care 2024;28(4):646−651; DOI: 10.35975/apic.v28i4.2506
Received: May 15, 2024; Reviewed: June 01, 2024; Accepted: June 22, 2024
Several studies addressing the clinical course of coronavirus disease-2019 (COVID-19) have identified possible risk factors for the transmission and severity of COVID-19.1–4 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, can target many organs in the human body, although the most affected organ in critically ill patients is the lung. Patients experiencing progressive respiratory distress due to COVID-19 are potential intensive-care patients. Acute respiratory distress syndrome (ARDS), which develops secondary to SARS-CoV-2 pneumonia, is the most common diagnosis, with a rate of 85-90% in COVID-19 patients treated in intensive care units (ICUs).5,6 Severe viral pneumonias causes severe ARDS that require invasive mechanical ventilation (IMV). According to the results of the 2016 large observational study to understand the global impact of severe acute respiratory failure (LUNG SAFE) study, non-COVID ARDS accounts for 10.4% of ICU admissions, with a very high mortality rate of approximately 40%.7 Although different mortality rates have been reported in studies conducted in various countries, the estimated overall pooled mortality rate of COVID-19-related ARDS is 39%, similar to that of non-COVID-19 ARDS.8
Pathophysiological changes that occur in the background of ARDS due to severe damage to the lung caused by the SARS-CoV-2 cause air leaks in some patients. Air leaks outside the tracheobronchial tree, such as pneumothorax, pneumomediastinum, and subcutaneous emphysema, are complications seen in patients with ARDS, breathing spontaneously or requiring mechanical ventilation. Spontaneous pneumothorax (SP) refers to the abnormal collection of air in the pleural space between the lung and the chest wall without any trauma. Although a few case series/reports regarding COVID-19-related SP and other air leak pathologies were published in the early periods of the pandemic, the number of observational studies on this subject has increased recently.9–12 The development of pneumothorax in patients has been attributed to the pathophysiology of ARDS in some studies and to barotrauma caused by mechanical ventilation in others. However, the effects of both ARDS pathogenesis and MV-induced barotrauma are intertwined in tracheobronchial air leaks in COVID-19 patients.
We carried out this study to investigate the clinical course and outcomes of patients with SP and accompanying pneumomediastinum, subcutaneous emphysema in patients admitted to the ICUs of our hospital due to ARDS secondary to COVID-19 viral pneumonia.
This study was designed as a single-center retrospective study. The study protocol was approved by the Medical Ethical Committee of Acibadem University (Approval number 2021-10/28).
The study population consisted of all critically ill adult patients, tested positive for COVID-19, developed SP, and were admitted to the intensive care units (ICUs) of Acibadem University School of Medicine Training and Research Hospital in March 21, 2020 to May 31, 2021. COVID-19 diagnosis was based on the real-time reverse transcription polymerase chain reaction (RT-PCR) testing of nasopharyngeal swabs or endotracheal aspirate specimens.
Of the 753 patients admitted to the ICUs during the study period, 600 tested positive for COVID-19 viral pneumonia. All patients underwent a chest computed tomography (CT) scan upon admission to the hospital. ARDS diagnosis was based on 2012 Berlin definitions.13 Of the 600 patients with COVID-19, 549 met the diagnostic criteria for ARDS. SP diagnosis was based on clinical documentation and chest X-ray imaging. Patients who developed SP at any time during the clinical course of COVID-19 were reviewed. Patients under 18 y, patients who were pregnant, followed up outside our ICU, and whose hospital data were missing or insufficient were excluded from the study. In the end, the study sample consisted of five patients who developed SP. The study’s flowchart is shown in Figure 1.
Of the 753 patients admitted to the ICUs during the study period, 600 tested positive for COVID-19 viral pneumonia. The overall mortality rate was 58.8% (n = 353). Of the 600 patients with COVID-19, 549 met the diagnostic criteria for ARDS, of whom 472 were treated with IMV and 77 were treated without IMV. Of the 549 patients with ARDS, 51 had COVID-19 viral pneumonia without ARDS. SP developed in a total of 5 (0.8%) patients, 4 (0.9%) of whom were on IMV support and 1 (1.2%) of whom was breathing spontaneously. The characteristics of patients with SP are summarized in Table 1.
Of the five patients who developed SP, one patient on IMV support was female, and the remaining four were male. The median age of these five patients was 42 (min. 33, max. 64) y. Two (40%) of the five patients died in ICU. None of the three surviving patients had chronic lung disease or any other comorbidities and had never smoked. Both patients who died had comorbidities. One had chronic obstructive pulmonary disease (COPD), and the other had chronic renal failure. Both were ex-smokers. Of the five patients with CP, the spontaneously breathing patient had mild ARDS, while the others who were on IMV support had severe ARDS. Chest CT scans revealed diffuse bilateral patchy ground glass opacities in surviving patients and consolidation and pleural effusion in deceased patients. Chest X-ray and CT scans of surviving and deceased cases are shown in Figures 2 and 3, respectively. Pneumothorax management was performed with chest drainage in all five patients. No significant difference was observed between these patients in terms of the side of the pneumothorax. Two had left-sided, two had right-sided, and one had bilateral SP. The characteristics of patients with SP are summarized in Table 1.
In this study, we investigated the incidence of SP in patients treated with or without IMV for COVID-19-related ARDS in our ICUs and the relevant clinical findings, course, and outcomes of these patients.
4.1. Incidence
A systematic review including nine observational studies reported the overall incidence of SP in hospitalized COVID-19 patients as 0,3% and between 12.8% and 23.8% in critically ill COVID-19 patients who required IMV.14 Zantah et al. reported the incidence of SP in hospitalized COVID-19 patients as 0.66%.10 Wang et al. found the incidence of SP as high as 56% in patients requiring IMV.14 In comparison, we found the overall incidence of SP in critically ill patients with COVID-19 and ARDS to be 0.83%. The incidence of SP was 0.9% in patients who required IMV and 1.2% in patients who did not require IMV.
4.2. Patients’ characteristics
In a retrospective multicenter study conducted by Ekanem et al., the median age of the COVID-19 patients with SP, 82% of whom were male, was 60 y.15 In comparison, in our study, the median age of five COVID-19 patients with SP, of whom 80% were male, was 42 years.
Another study reported that most SP cases had unilateral, right-sided SP.16 In comparison, most (80%) of our SP cases also had unilateral SP, but there was no significant difference between these patients in terms of the side of the pneumothorax.
Lastly, several studies reported that most SP cases required chest tube drainage within the scope of SP management in COVID-19 ARDS.10,14,15 In comparison, all of our cases required chest tube drainage.
4.3. Risk factors
ARDS is an independent risk factor for SP in patients receiving IMV support.17 In other words, pathophysiological changes in the lungs in ARDS cause high airway pressure rather than mechanical ventilation, causing barotrauma.17,18 It is the barotrauma caused by mechanical ventilation added to the inflammatory process in the lung parenchyma that affects oxygenation, weaning, and survival in COVID-19 ARDS patients, rather than the lung diseases already present in most patients. As a matter of fact, four of our SP cases did not have any chronic pulmonary disease and did not smoke. Some studies have shown that smoking does not increase the risk of hospitalization or the development of critical illness in COVID-19 patients.19 The lung-protective ventilation strategy has been correlated with a higher rate of weaning from mechanical ventilation and a lower rate of barotrauma in patients with ARDS.20 In addition, prone positioning during mechanical ventilation has been reported to improve survival in ARDS patients receiving protective lung ventilation.21–23 None of our SP cases were placed in the prone position. However, the lung-protective ventilation strategy was applied in 4 cases requiring IMV. Two (50%) of these 4 cases were lost. Four of the SP cases included in our sample were 40 years of age or younger.
4.4. Outcomes
SP-related mortality rates in COVID-19 patients reported in the literature vary between 2.9% and 88%.10,14,15,24,25 In comparison, SP-related mortality of the critically ill COVID-19 patients included in our sample was 40%. Chest CT scans of our deceased patients taken at the time of their admission to ICU revealed consolidation and pleural effusion, unlike our surviving patients. Additionally, both of our deceased patients had comorbidities. While the one over the age of 65 had a chronic lung disease, the one under the age of 40 was on a routine hemodialysis program due to chronic renal failure.
The study’s primary limitation was its retrospective design; that is, patient data were accessed from hospital records, and therefore, detailed medical records were not available.
The study’s secondary limitation was its single-center design; only patients in the ICU of a city hospital were included in the study population.
Spontaneous pneumothorax is a life-threatening complication that requires rapid diagnosis and urgent treatment in COVID-19 patients with severe respiratory failure, with or without IMV support. Our study’s findings indicate that COVID-19-related spontaneous pneumothorax may prolong the stay of patients in the ICU and hospital, and may cause an increase in mortality rates, especially in those over 65 years of age and with comorbidities. It may not be possible to precisely determine the incidence and mortality rate of spontaneous pneumothorax with retrospective studies conducted under pandemic conditions. Therefore, future prospective observational studies are needed to reach more definitive conclusions.
7. Data availability
The numerical data generated during this research is available with the authors.
8. Acknowledgement
We gratefully thank Faculty of Medicine
9. Conflict of interest
The study utilized the hospital resources only, and no external or industry funding was involved.
10. Authors’ contribution
DH: Concept, conduct of the study, translation
EUH: Statistical analysis, collection of the patient data, editing the draft manuscript
Author affiliations:
- Deniz Heppekcan, Cevizli Mah. 30 Ağustos Cad. No 9-11 Başyapıt Dragos Daire:83 Maltepe-İstanbul-Turkey; {ORCID: 0000-0002-3217-1387}
- Egemen Ümit Hazar, Zonguldak Atatürk Devlet Hastanesi, Meşrutiyet, Uzun Mehmet Cd. No:5, 67030 Zonguldak -Turkey; E-mail: egemenumithazar@gmail.com; {ORCID: 0009-0009-8133-1525}
ABSTRACT
Background & Objective: Coronavirus disease 2019 (COVID-19) claimed thousands of the lives during a limited period of time, but also enriched our scientific knowledge, especially regarding the respiratory pathogenesis and intensive care dynamics. This study was carried out to bridge the gap in the literature regarding the incidence, clinical features, and outcomes of spontaneous pneumothorax (SP) that develops during the course of COVID-19.
Methodology: The population of this single-center retrospective study consisted of all critically ill adult patients who tested positive for COVID-19, developed SP, and were admitted to the intensive care units (ICUs) of Acibadem University School of Medicine, Training and Research Hospital, between March 21, 2020 and May 31, 2021. Detailed medical records, clinical findings, chest computed tomography (CT) scans, and X-ray images of critically ill COVID-19 patients complicated by SP were obtained and analyzed.
Results: Of the 753 patients admitted to the ICUs during the study period, 600 tested positive for COVID-19 viral pneumonia. Of these patients, 549 met the diagnostic criteria for acute respiratory distress syndrome (ARDS), of whom 472 were treated with invasive mechanical ventilation (IMV) and 77 were treated without IMV. SP developed in a total of five (0.8%) patients, 4 (0.9%) of whom were on IMV support and 1 (1.2%) of whom was breathing spontaneously. Of these patients who developed SP, one patient on IMV support was female, and the remaining four were male. The median age of these five patients was 42 (33-64) years. Two (40%) of the five patients died in ICU.
Conclusion: The actual incidence of COVID-19-related spontaneous pneumothorax is yet to be elucidated and may require a large scale, multi-center study. COVID-19-related spontaneous pneumothorax is similar to ARDS-related spontaneous pneumothorax without COVID-19 in terms of clinical features and outcomes, its risk of occurrence is higher.
Abbreviations: COVID-19 - Coronavirus disease 2019; CT - computed tomography; IMV - invasive mechanical ventilation; SP - spontaneous pneumothorax
Keywords: SARS-Cov-2; COVID-19; Spontaneous Pneumothorax
Citation: Heppekcan D, Hazar EU. Spontaneous pneumothorax in critically ill patients with COVID-19. Anaesth. pain intensive care 2024;28(4):646−651; DOI: 10.35975/apic.v28i4.2506
Received: May 15, 2024; Reviewed: June 01, 2024; Accepted: June 22, 2024
1. INTRODUCTION
Several studies addressing the clinical course of coronavirus disease-2019 (COVID-19) have identified possible risk factors for the transmission and severity of COVID-19.1–4 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19, can target many organs in the human body, although the most affected organ in critically ill patients is the lung. Patients experiencing progressive respiratory distress due to COVID-19 are potential intensive-care patients. Acute respiratory distress syndrome (ARDS), which develops secondary to SARS-CoV-2 pneumonia, is the most common diagnosis, with a rate of 85-90% in COVID-19 patients treated in intensive care units (ICUs).5,6 Severe viral pneumonias causes severe ARDS that require invasive mechanical ventilation (IMV). According to the results of the 2016 large observational study to understand the global impact of severe acute respiratory failure (LUNG SAFE) study, non-COVID ARDS accounts for 10.4% of ICU admissions, with a very high mortality rate of approximately 40%.7 Although different mortality rates have been reported in studies conducted in various countries, the estimated overall pooled mortality rate of COVID-19-related ARDS is 39%, similar to that of non-COVID-19 ARDS.8
Pathophysiological changes that occur in the background of ARDS due to severe damage to the lung caused by the SARS-CoV-2 cause air leaks in some patients. Air leaks outside the tracheobronchial tree, such as pneumothorax, pneumomediastinum, and subcutaneous emphysema, are complications seen in patients with ARDS, breathing spontaneously or requiring mechanical ventilation. Spontaneous pneumothorax (SP) refers to the abnormal collection of air in the pleural space between the lung and the chest wall without any trauma. Although a few case series/reports regarding COVID-19-related SP and other air leak pathologies were published in the early periods of the pandemic, the number of observational studies on this subject has increased recently.9–12 The development of pneumothorax in patients has been attributed to the pathophysiology of ARDS in some studies and to barotrauma caused by mechanical ventilation in others. However, the effects of both ARDS pathogenesis and MV-induced barotrauma are intertwined in tracheobronchial air leaks in COVID-19 patients.
We carried out this study to investigate the clinical course and outcomes of patients with SP and accompanying pneumomediastinum, subcutaneous emphysema in patients admitted to the ICUs of our hospital due to ARDS secondary to COVID-19 viral pneumonia.
2. METHODOLOGY
This study was designed as a single-center retrospective study. The study protocol was approved by the Medical Ethical Committee of Acibadem University (Approval number 2021-10/28).
The study population consisted of all critically ill adult patients, tested positive for COVID-19, developed SP, and were admitted to the intensive care units (ICUs) of Acibadem University School of Medicine Training and Research Hospital in March 21, 2020 to May 31, 2021. COVID-19 diagnosis was based on the real-time reverse transcription polymerase chain reaction (RT-PCR) testing of nasopharyngeal swabs or endotracheal aspirate specimens.
Of the 753 patients admitted to the ICUs during the study period, 600 tested positive for COVID-19 viral pneumonia. All patients underwent a chest computed tomography (CT) scan upon admission to the hospital. ARDS diagnosis was based on 2012 Berlin definitions.13 Of the 600 patients with COVID-19, 549 met the diagnostic criteria for ARDS. SP diagnosis was based on clinical documentation and chest X-ray imaging. Patients who developed SP at any time during the clinical course of COVID-19 were reviewed. Patients under 18 y, patients who were pregnant, followed up outside our ICU, and whose hospital data were missing or insufficient were excluded from the study. In the end, the study sample consisted of five patients who developed SP. The study’s flowchart is shown in Figure 1.
| Table 1: Demographic and clinical details of all SP cases | |||||
| Parameter | Case 1 (SB) | Case 2 (ME) | Case 3 (GC) | Case 4 (RC) | Case 5 (MA) |
| Sex
Age (Y) Smoking history Ch. lung disease Rt-PCR Other comorbidities |
Male 33 N.S No + No |
Male 38 N.S No + No |
Female 40 N.S No + No |
Male 64 Ex-S Yes + Yes |
Male 38 N.S No + Yes |
| Side of SP
Day of SP Subcutaneous emphysema Pneumomediastinum Severity of ARDS |
Left 15 No No Mild |
Left 26 No No Severe |
Right 22 No No Severe |
Bilateral 3 Yes No Severe |
Right 31 Yes Yes Severe |
| Mode of Breathing
Mode of Diagnosis IMV duration before SP (day) |
Spontaneous Breathing Clinical Change N/A |
IMV Clinical Change 25 |
IMV Clinical Change 7 |
IMV Clinical Change 1 |
IMV Clinical Change 12 |
| Management of PT
Neuromuscular blockers Recruitment maneuver Lung-protective ventilation Prone position ECMO |
Chest Drain N/A N/A N/A No N/A |
Chest Drain Yes Yes Yes No No |
Chest Drain Yes Yes Yes No No |
Chest Drain Yes Yes Yes No No |
Chest Drain Yes No Yes No No |
| CT features: (on admission) Ground- glass opacity Consolidation Fibrosis Pulmonary cysts Emphysema Pleural Effusion |
Yes Yes No No No No |
Yes No No No No No |
Yes No No No No No |
No Yes No No No Yes |
Yes Yes No No No Yes |
| Outcome
From occurrence of SP to death (days) Length of hospital stay (days) |
Alive N/A 28 |
Alive N/A 114 |
Alive N/A 40 |
Died 7 11 |
Died 1 32 |
3. RESULTS
Of the 753 patients admitted to the ICUs during the study period, 600 tested positive for COVID-19 viral pneumonia. The overall mortality rate was 58.8% (n = 353). Of the 600 patients with COVID-19, 549 met the diagnostic criteria for ARDS, of whom 472 were treated with IMV and 77 were treated without IMV. Of the 549 patients with ARDS, 51 had COVID-19 viral pneumonia without ARDS. SP developed in a total of 5 (0.8%) patients, 4 (0.9%) of whom were on IMV support and 1 (1.2%) of whom was breathing spontaneously. The characteristics of patients with SP are summarized in Table 1.
Of the five patients who developed SP, one patient on IMV support was female, and the remaining four were male. The median age of these five patients was 42 (min. 33, max. 64) y. Two (40%) of the five patients died in ICU. None of the three surviving patients had chronic lung disease or any other comorbidities and had never smoked. Both patients who died had comorbidities. One had chronic obstructive pulmonary disease (COPD), and the other had chronic renal failure. Both were ex-smokers. Of the five patients with CP, the spontaneously breathing patient had mild ARDS, while the others who were on IMV support had severe ARDS. Chest CT scans revealed diffuse bilateral patchy ground glass opacities in surviving patients and consolidation and pleural effusion in deceased patients. Chest X-ray and CT scans of surviving and deceased cases are shown in Figures 2 and 3, respectively. Pneumothorax management was performed with chest drainage in all five patients. No significant difference was observed between these patients in terms of the side of the pneumothorax. Two had left-sided, two had right-sided, and one had bilateral SP. The characteristics of patients with SP are summarized in Table 1.
4. DISCUSSION
In this study, we investigated the incidence of SP in patients treated with or without IMV for COVID-19-related ARDS in our ICUs and the relevant clinical findings, course, and outcomes of these patients.
4.1. Incidence
A systematic review including nine observational studies reported the overall incidence of SP in hospitalized COVID-19 patients as 0,3% and between 12.8% and 23.8% in critically ill COVID-19 patients who required IMV.14 Zantah et al. reported the incidence of SP in hospitalized COVID-19 patients as 0.66%.10 Wang et al. found the incidence of SP as high as 56% in patients requiring IMV.14 In comparison, we found the overall incidence of SP in critically ill patients with COVID-19 and ARDS to be 0.83%. The incidence of SP was 0.9% in patients who required IMV and 1.2% in patients who did not require IMV.
4.2. Patients’ characteristics
In a retrospective multicenter study conducted by Ekanem et al., the median age of the COVID-19 patients with SP, 82% of whom were male, was 60 y.15 In comparison, in our study, the median age of five COVID-19 patients with SP, of whom 80% were male, was 42 years.
Another study reported that most SP cases had unilateral, right-sided SP.16 In comparison, most (80%) of our SP cases also had unilateral SP, but there was no significant difference between these patients in terms of the side of the pneumothorax.
Lastly, several studies reported that most SP cases required chest tube drainage within the scope of SP management in COVID-19 ARDS.10,14,15 In comparison, all of our cases required chest tube drainage.
4.3. Risk factors
ARDS is an independent risk factor for SP in patients receiving IMV support.17 In other words, pathophysiological changes in the lungs in ARDS cause high airway pressure rather than mechanical ventilation, causing barotrauma.17,18 It is the barotrauma caused by mechanical ventilation added to the inflammatory process in the lung parenchyma that affects oxygenation, weaning, and survival in COVID-19 ARDS patients, rather than the lung diseases already present in most patients. As a matter of fact, four of our SP cases did not have any chronic pulmonary disease and did not smoke. Some studies have shown that smoking does not increase the risk of hospitalization or the development of critical illness in COVID-19 patients.19 The lung-protective ventilation strategy has been correlated with a higher rate of weaning from mechanical ventilation and a lower rate of barotrauma in patients with ARDS.20 In addition, prone positioning during mechanical ventilation has been reported to improve survival in ARDS patients receiving protective lung ventilation.21–23 None of our SP cases were placed in the prone position. However, the lung-protective ventilation strategy was applied in 4 cases requiring IMV. Two (50%) of these 4 cases were lost. Four of the SP cases included in our sample were 40 years of age or younger.
4.4. Outcomes
SP-related mortality rates in COVID-19 patients reported in the literature vary between 2.9% and 88%.10,14,15,24,25 In comparison, SP-related mortality of the critically ill COVID-19 patients included in our sample was 40%. Chest CT scans of our deceased patients taken at the time of their admission to ICU revealed consolidation and pleural effusion, unlike our surviving patients. Additionally, both of our deceased patients had comorbidities. While the one over the age of 65 had a chronic lung disease, the one under the age of 40 was on a routine hemodialysis program due to chronic renal failure.
5. LIMITATIONS
The study’s primary limitation was its retrospective design; that is, patient data were accessed from hospital records, and therefore, detailed medical records were not available.
The study’s secondary limitation was its single-center design; only patients in the ICU of a city hospital were included in the study population.
6. CONCLUSION
Spontaneous pneumothorax is a life-threatening complication that requires rapid diagnosis and urgent treatment in COVID-19 patients with severe respiratory failure, with or without IMV support. Our study’s findings indicate that COVID-19-related spontaneous pneumothorax may prolong the stay of patients in the ICU and hospital, and may cause an increase in mortality rates, especially in those over 65 years of age and with comorbidities. It may not be possible to precisely determine the incidence and mortality rate of spontaneous pneumothorax with retrospective studies conducted under pandemic conditions. Therefore, future prospective observational studies are needed to reach more definitive conclusions.
7. Data availability
The numerical data generated during this research is available with the authors.
8. Acknowledgement
We gratefully thank Faculty of Medicine
9. Conflict of interest
The study utilized the hospital resources only, and no external or industry funding was involved.
10. Authors’ contribution
DH: Concept, conduct of the study, translation
EUH: Statistical analysis, collection of the patient data, editing the draft manuscript
11. REFERENCES
- Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62. [PubMed] DOI: 1016/S0140-6736(20)30566-3
- Auld SC, Caridi-Scheible M, Blum JM, Robichaux CJ, Kraft C, Jacob JT, et al. ICU and ventilator mortality among critically ill adults with coronavirus disease 2019. Crit Care Med. 2020;48(9). [PubMed] DOI: 1097/CCM.0000000000004457
- Li J, Huang DQ, Zou B, Yang H, Hui WZ, Rui F, et al. Epidemiology of COVID‐19: A systematic review and meta‐analysis of clinical characteristics, risk factors, and outcomes. J Med Virol. 2021;93(3):1449-58. [PubMed] DOI: 1002/jmv.26424
- Tan E, Song J, Deane AM, Plummer MP. Global impact of coronavirus disease 2019 infection requiring admission to the ICU. Chest. 2021;159(2):524-36. [PubMed] DOI: 1016/j.chest.2020.10.014
- Ferrando C, Mellado-Artigas R, Gea A, Arruti E, Aldecoa C, Bordell A, et al. Características, evolución clínica y factores asociados a la mortalidad en UCI de los pacientes críticos infectados por SARS-CoV-2 en España: estudio prospectivo, de cohorte y multicéntrico. Rev Esp Anestesiol Reanim. 2020;67(7):425-37. [PubMed] DOI: 1016/j.redar.2020.07.003
- Serafim RB, Póvoa P, Souza-Dantas VC, Kalil AC, Salluh JI. Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review. Clin Microbiol Infect. 2021;27(1):47-54. [PubMed] DOI: 1016/j.cmi.2020.10.017
- Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788-800. [PubMed] DOI: 1001/jama.2016.0291
- Hasan SS, Capstick T, Ahmed R, Kow CS, Mazhar F, Merchant HA, et al. Mortality in COVID-19 patients with acute respiratory distress syndrome and corticosteroids use: a systematic review and meta-analysis. Expert Rev Respir Med. 2020;14(11):1149-63. [PubMed] DOI: 1080/17476348.2020.1804365
- Martinelli AW, Ingle T, Newman J, Nadeem I, Jackson K, Lane ND, et al. COVID-19 and pneumothorax: a multicentre retrospective case series. Eur Respir J. 2020;56(5):2002697. [PubMed] DOI: 1183/13993003.02697-2020
- Zantah M, Dominguez Castillo E, Townsend R, Dikengil F, Criner GJ. Pneumothorax in COVID-19 disease-incidence and clinical characteristics. Respir Res. 2020;21(1):236. [PubMed] DOI: 1186/s12931-020-01504-y
- Capaccione KM, D'souza B, Leb J, Garcia JA, Friede R, Salvatore MM, et al. Pneumothorax rate in intubated patients with COVID-19. Acute Crit Care. 2021;36(1):81-4. [PubMed] DOI: 4266/acc.2020.00689
- Chong WH, Saha BK, Hu K, Chopra A. The incidence, clinical characteristics, and outcomes of pneumothorax in hospitalized COVID-19 patients: a systematic review. Heart Lung. 2021;50(6):599-608. [PubMed] DOI: 1016/j.hrtlng.2021.04.005
- Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526-33. [PubMed] DOI: 1001/jama.2012.5669
- Wang X, Duan J, Han L, Guo S, Wang H, Wang S, et al. High incidence and mortality of pneumothorax in critically ill patients with COVID-19. Heart Lung. 2021;50(1):37-43. [PubMed] DOI: 1016/j.hrtlng.2020.10.002
- Ekanem E, Podder S, Donthi N, Baca G, Zhong E, Chang A, et al. Spontaneous pneumothorax: An emerging complication of COVID-19 pneumonia. Heart Lung. 2021;50(3):437-40. [PubMed] DOI: 1016/j.hrtlng.2021.01.020
- McGuinness G, Zhan C, Rosenberg N, Azour L, Wickstrom M, Mason DM, et al. Increased incidence of barotrauma in patients with COVID-19 on invasive mechanical ventilation. Radiology. 2020;297(2). [PubMed] DOI: 1148/radiol.2020202352
- Gammon RB, Shin MS, Groves RH Jr, Hardin JM, Hsu C, Buchalter SE, et al. Clinical risk factors for pulmonary barotrauma: a multivariate analysis. Am J Respir Crit Care Med. 1995;152(4 Pt 1):1235-40. [PubMed] DOI: 1164/ajrccm.152.4.7551376
- Weg JG, Anzueto A, Balk RA, Wiedemann HP, Pattishall EN, Schork MA, et al. The relation of pneumothorax and other air leaks to mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):341-6. [PubMed] DOI: 1056/NEJM199802053380601
- Petrilli CM, Jones SA, Yang J, Rajagopalan H, O'Donnell L, Chernyak Y, et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ. 2020;369. [PubMed] DOI: 1136/bmj.m1966
- Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338(6):347-54. [PubMed] DOI: 1056/NEJM199802053380602
- Aoyama H, Pettenuzzo T, Aoyama K, Miskovic A, Englesakis M, Fan E, et al. Assessment of therapeutic interventions and lung protective ventilation in patients with moderate to severe acute respiratory distress syndrome: a systematic review and network meta-analysis. JAMA Netw Open. 2019;2(7). [PubMed] DOI: 1001/jamanetworkopen.2019.8116
- Sud S, Friedrich JO, Adhikari NK, Taccone P, Mancebo J, Polli F, et al. Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: a systematic review and meta-analysis. CMAJ. 2014;186(10). [PubMed] DOI: 1503/cmaj.140081
- Mora-Arteaga JA, Bernal-Ramírez OJ, Rodríguez SJ. The effects of prone position ventilation in patients with acute respiratory distress syndrome. A systematic review and meta-analysis. Med Intensiva. 2015;39(6):359-72. [PubMed] DOI: 1016/j.medin.2014.11.003
- Guo T, Shen Q, Guo W, He W, Li J, Zhang Y, et al. Clinical characteristics of elderly patients with COVID-19 in Hunan Province, China: a multicenter, retrospective study. Gerontology. 2020;66(5):467-75. [PubMed] DOI: 1159/000508734
- Cates J, Lucero-Obusan C, Dahl RM, Schirmer P, Garg S, Oda G, et al. Risk for in-hospital complications associated with COVID-19 and influenza—Veterans Health Administration, United States, October 1, 2018–May 31, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(42):1528-34. [PubMed] DOI: 15585/mmwr.mm6942e3