BILATERAL PNEUMOTHORACES AS A COMPLICATION OF COVID-19

ABSTRACT

CASE A 40-year-old man with no significant past medical history presented with acute hypoxemic, hypercarbic respiratory failure and was diagnosed with COVID-19 pneumonia. He reported that he was unvaccinated against SARSCoV-2. Over the course of two months, he required high-flow nasal cannula, continuous then nocturnal BIPAP for respiratory support and completed appropriate courses of dexamethasone, remdesivir, and baricitinib. He also completed a course of levofloxacin due to concern for superimposed bacterial pneumonia. After finishing the course of dexamethasone, the patient was initiated on a prolonged prednisone taper. His course was complicated by the development of fibroproliferative acute respiratory distress syndrome two months after his initial diagnosis of COVID- 19 requiring continuous followed by nocturnal BIPAP to maintain adequate oxygenation. Subsequently, he developed recurrent bilateral, spontaneous pneumothoraces, which required the insertion of multiple chest tubes due to ongoing air leaks and continued recurrence on removal. IMPACT/DISCUSSION: Acute respiratory distress syndrome (ARDS) leads to diffuse alveolar damage in the lung and is increasingly being seen as a complication of COVID-19. These patients frequently require steroids along with positive pressure ventilation to maintain adequate oxygenation. Pneumothorax is a common and sometimes fatal complication of positive pressure ventilation in patients with acute respiratory distress syndrome, with some studies quoting an incidence as high as 48%. On the other hand, development of spontaneous pneumothorax in patients with COVID-19 pneumonia is much more rare, with studies showing an incidence of approximately 1% and usually upon the initiation of invasive mechanical ventilation, with collapse due to barotrauma in the setting of cystic and fibrotic changes in the lung parenchyma. However, there are no current case reports citing pneumothoraces as late complications of COVID-19 ARDS, as occurred in our patient two months into his hospitalization, and related solely to BiPAP use in a patient who never previously underwent endotracheal intubation or ventilation. Additionally, since corticosteroids delay wound healing, it is critical to recognize the possibility of developing spontaneous, recurrent pneumothoraces in patients with COVID-19 on prolonged steroid tapers who are initiating any form of positive pressure ventilation, including non-invasive ventilation such as BIPAP. CONCLUSION: Pneumothoraces are rare complications of COVID-19 pneumonia, and are most commonly seen in males who undergo endotracheal intubation. Corticosteroids delay wound healing, and prolonged steroid tapers increase the risk of recurrent pneumothoraces once one develops. Clinicians must be wary of this rare, late complication of patients with COVID-19 ARDS and prolonged steroid exposure and should be extra judicious with the use of positive pressure ventilation.