Spontaneous Pneumothorax in COVID-19: A Report of Two Patients

ABSTRACT

Aim and background: Coronavirus disease 2019 [SARS-CoV-2] is a serious infectious disease which can cause multiple organ failures especially the lungs. Supportive treatment including invasive and non-invasive oxygen support remains a common therapy. High-flow nasal cannula [HFNC], a non-invasive oxygen support method, has emerged as effective treatment option. Despite its significance in SARS-CoV-2 infection, there is a possible adverse effect of pneumothorax. Many cases of pneumothorax are reported as an initial presentation of COVID-19 infection, but in this report, we present two cases of spontaneous pneumothorax on HFNC in COVID-19 infection. Case 1 A 47-year-old patient, known case of hypertension, got admitted for COVID treatment at our hospital. His PaO2/FiO2 index was 47 on admission and the specific treatment started including non-invasive ventilation. Subsequently, he was put on HFNC to maintain oxygen support. He developed newlyonset cough 4 days prior to pneumothorax. After 13 days on HFNC, right-sided spontaneous pneumothorax developed as a complication. Chest X-ray and lung ultrasound were done to confirm pneumothorax, and a tube thoracostomy was done. However, patient had to be intubated the next day because of decreased saturation on NIV and he died after 2 days of intubation. Case 2 A 34-year-old patient got admitted for COVID-19 pneumonia, without any comorbidities. His PaO2/FiO2 index was 86 on admission and the specific treatment started including non-invasive ventilation. Thereafter, he was put on HFNC to maintain oxygen support. The patient developed cough 5 days prior to pneumothorax. After 8 days on HFNC, patient's oxygen saturation dropped suddenly. He was intubated in emergency, however, suffered cardiac arrest, a few minutes after intubation. Chest X-ray done later showed leftsided massive pneumothorax. Conclusion: Patients on mechanical ventilation are at risk of developing spontaneous pneumothorax. However, HFNC may also be associated with higher chances of barotrauma than other low-flow oxygen therapies, especially in addition to cough. Rapid deterioration of oxygen in a patient on HFNC should be vigilantly monitored for pneumothorax.