Expectant management of pneumothorax in intubated COVID-19 positive patients: a case series
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(2020) 15:263
CASE REPORT
Open Access
Expectant management of pneumothorax in intubated COVID-19 positive patients: a case series Colby Elder1* , Sheina Bawa1, Douglas Anderson1, Stephen Atkinson2, Joshua Etzel2 and Troy Moritz1
Abstract Background: There is an increasing amount of literature describing the pathogenesis of coronavirus disease 2019 (COVID-19) pneumonia and its associated complications. Historically, a small pneumothorax has been shown to be successfully treated without chest tube insertion, but this management has yet to be proven in COVID-19 pneumonia patients. In addition, pneumothorax in an intubated patient with high positive end-expiratory pressure (PEEP) provides additional uncertainty with pursuing non-operative management. Case presentation: In this series we report four cases of patients with respiratory distress who tested positive for COVID-19 via nasopharyngeal swab and developed ventilator-induced pneumothoraces which were successfully managed with observation alone. Conclusions: Management of patients with COVID-19 pneumonia on positive pressure ventilation who develop small stable pneumothoraces can be safely observed without chest tube insertion. Keywords: COVID-19, Pneumothorax, Case report
Introduction COVID-19 pneumonia may cause cystic features of lung parenchyma which can resolve or progress to larger blebs [1, 2]. This can place patients at risk for rupture resulting in mediastinal and subcutaneous emphysema or secondary spontaneous pneumothorax. Many are intubated and placed on low tidal volume and high PEEP ventilation therapy which further increases concern for rupture. For critically ill patients on positive pressure ventilation, although controversial, it is currently recommended to place a tube thoracostomy when a pneumothorax is observed [3]. Due to limited knowledge of lung histopathology with COVID-19, it is unknown how well the diseased lung tissue will spontaneously heal and reexpand without intervention. For moderate to large * Correspondence: [email protected] 1 UPMC Pinnacle Harrisburg, 205 S. Front St. Brady Hall 9th Floor, Room 96, Harrisburg, PA 17104, USA Full list of author information is available at the end of the article
pneumothorax and prolonged air leak, there have been reports of successful treatment with video-assisted thoracoscopic surgery and wedge resection [4]. There have also been explanations on how to contain viral dissemination by using bespoke viral filtration systems to limit contamination [5]. However, for a small pneumothorax in a stable patient, chest tube placement may be second line to watchful waiting. We present four cases of pneumothorax in COVID-19 positive patients who were managed without chest tube placement despite being on positive pressure ventilation.
Cases Case 1
A 48-year-old male with hypertension and hyperlipidemia without a history of cigarette smoking presented to the emergency (ED) with 1 week of a worsening dry cough associated with chest pain, headaches, myalgia, shortness of breath, and subjective fevers. A c
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