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Pneumothorax in Otherwise Healthy Non-Intubated Patients Suffering from COVID-19 Pneumonia: a Systematic Review

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Pneumothorax in Otherwise Healthy Non-Intubated Patients Suffering from COVID-19 Pneumonia: a Systematic Review 4529 Review Article Pneumothorax in otherwise healthy non-intubated patients suffering from COVID-19 pneumonia: a systematic review Apostolos C. Agrafiotis1^, Peter Rummens2, Ines Lardinois1 1Department of Thoracic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium; 2Department of Respiratory Medicine, Saint-Pierre University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium Contributions: (I) Conception and design: AC Agrafiotis; (II) Administrative support: P Rummens, I Lardinois; (III) Provision of study materials or patients: AC Agrafiotis, P Rummens; (IV) Collection and assembly of data: AC Agrafiotis, P Rummens; (V) Data analysis and interpretation: AC Agrafiotis, P Rummens; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Dr. Apostolos C. Agrafiotis. Department of Thoracic Surgery, Saint-Pierre University Hospital, Rue Haute 322, 1000 Brussels, Belgium. Email: [email protected]. Background: Cases of spontaneous pneumothorax have been described in patients suffering from coronavirus disease 2019 (COVID-19) pneumonia. The aim of this study is to systematically review all the cases of spontaneous pneumothorax that occurred in healthy patients with no underlying lung disease and who did not receive invasive mechanical ventilation. Methods: A PubMed research was conducted. The following data were collected: age, sex, side of the pneumothorax, smoking habit, time form onset of symptoms to the diagnosis of pneumothorax, the development of new bullous lesions on computed tomography and the type of treatment. In order to analyze the most homogeneous population possible, intubated patients were deliberately excluded. In total, 44 cases of spontaneous pneumothorax in otherwise healthy patients were taken into account. Since the available data were extracted from small observational studies, no particular bias risk assessment was performed. Descriptive statistics were used to synthesize results. Results: There were 37 male (84.1%) and 6 female (13.6%) patients. The majority of patients (66%) were treated only by chest tube thoracostomy, which most of the times resulted in a complete resolution of the pneumothorax. Simple surveillance was applied in 10 cases. Three patients underwent minimally invasive surgery. In 14 cases (31.8%) air-filled lesions were detected on imaging. Eleven patients received corticosteroids during their hospital stay. In the majority of cases (86.3%) the pneumothorax was resolved. Discussion: Even if the level of evidence, derived from case reports and small case series is low, the existence of a true secondary spontaneous pneumothorax due to SARS-CoV-2 should be recognized. Imaging techniques should be repeated throughout the clinical course of the patients in order to detect newly developed pulmonary complications. Surgical treatment is feasible and patients whose general condition permits, should be offered surgery according to the existing guidelines regarding spontaneous pneumothorax. National registries and databases are necessary in order to better understand the pathogenesis and complications of this novel entity. Keywords: Coronavirus disease 2019 (COVID-19); pneumothorax; pneumonia Submitted Jan 31, 2021. Accepted for publication Apr 23, 2021. doi: 10.21037/jtd-21-208 View this article at: https://dx.doi.org/10.21037/jtd-21-208 ^ ORCID: 0000-0002-7525-2080. © Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(7):4519-4529 | https://dx.doi.org/10.21037/jtd-21-208 4520 Agrafiotis et al. Pneumothorax in non-intubated COVID-19 patients Introduction The initial research resulted in 108 articles. After analysis of the titles and/or abstracts, 35 articles were excluded After the increasing report of cases of severe respiratory as being irrelevant to the topic. From the remaining 73 infections caused by a novel coronavirus, known as articles, 4 were excluded because the patients were less coronavirus 2 (SARS-CoV-2) in late 2019, the outbreak than 18 years old. Three additional articles were excluded occurred during the following months was declared as because, even if they were relevant to the topic, they were a global pandemic by the World Health Organization published in another language than English. One article (WHO) (1). The WHO named this spectrum of infections could not be retrieved. From the remaining 65 articles, after as coronavirus disease 2019 (COVID-19) (1). According to lecture and analysis, 29 more articles were excluded (articles the WHO update on November 2020, there were almost reporting on critically ill patients that needed intubation 51 million confirmed cases and more than 1.26 million deaths and mechanical ventilation, a review of all pleural diseases attributed to COVID-19 in more than 219 countries (1). related to COVID-19, a review relevant to the topic but The respiratory symptoms can vary from a self-limited upper describing a heterogeneous population of patients, articles respiratory infection to a massive pulmonary involvement reporting on patients with underlying lung disease, patients with respiratory failure, acute respiratory distress syndrome that presented only spontaneous pneumomediastinum and (ARDS) and a state of hypercoagulability (2,3). As experience articles containing recommendations about the treatment was gained with this new disease combined with the more of COVID-19-related pneumothorax). Finally, 36 articles liberal use of imaging techniques, for diagnostic and screening (case reports and small case series) relevant to the topic purposes, different radiological patterns of COVID-19 were analyzed. The references of these articles were cross- pneumonia have been identified (3-5). Cases of spontaneous checked in order to identify more cases. In total, 44 cases pneumothorax have been described in patients suffering of spontaneous pneumothorax in otherwise healthy patients from COVID-19 pneumonia (6-30). Pneumothoraces have with no underlying lung disease that did not necessitate been observed either as a first manifestation of the disease orotracheal intubation or invasive mechanical ventilation, or in a later phase, especially in patients that necessitated before or after the diagnosis of pneumothorax were taken orotracheal intubation and mechanical ventilation (31-49). into account. The flowchart of study selection process is The aim of this study is to systematically review all the cases shown on Figure 1. Since the available data were extracted of spontaneous pneumothorax that occurred in otherwise from small observational studies, no particular bias risk healthy patients with no underlying lung disease and who assessment was performed. were not put under invasive mechanical ventilation and The following data were collected: age, sex, the side detect similarities and differences comparing to spontaneous of the pneumothorax, the smoking habit, the time from pneumothorax encountered before the emergence of this onset of symptoms (or from hospital admission where the new entity. onset of symptoms was not clearly stated) to the diagnosis We present the following article in accordance with the of pneumothorax, notable characteristics on computed PRISMA reporting checklist (available at https://dx.doi. tomography (CT) scan (especially the development of new org/10.21037/jtd-21-208). bullous lesions) and the type of treatment. The presence of pneumomediastinum, subcutaneous emphysema or Methods pneumopericardium in addition to the pneumothorax were added to the analysis. In cases where surgical treatment A PubMed research was conducted using the terms was performed, intraoperative and pathological findings [Pneumothorax] AND [COVID-19] in November 2020. were taken into account. Data concerning administration This review was conducted according to the Preferred of corticosteroids and oxygen therapy (other than invasive Reporting Items for Systematic Reviews and Meta-Analyses mechanical ventilation) were retrieved. Whenever case (PRISMA) statement for a systematic review (PRISMA, series including intubated and non-intubated patients were www.prisma-statement.org) (50). Two reviewers (AA encountered, only the latter were included in the analysis. and PR) worked independently in order to conduct the Patients who presented an underlying lung pathology or research and the collection of data. Any discrepancies were other predisposing factors that could result in spontaneous resolved by consensus after discussion. Since this is a newly pneumothorax were excluded. described entity, all the articles were published in 2020. In order to analyze the most homogeneous population © Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2021;13(7):4519-4529 | https://dx.doi.org/10.21037/jtd-21-208 Journal of Thoracic Disease, Vol 13, No 7 July 2021 4521 Records identified through database searching (n=108) Identification Records excluded Records screened (Irrelevant articles) (n=108) (n=35) Full-text articles assessed for eligibility Full-text articles excluded (n=37) Screening (n=73) • Language other than English (n=3) • Patients <18 years old (n=4) • One article not found (n =1) Articles rejected after lecture as being irrelevant (n=29): • Critically-ill and intubated patients Eligibility (n=17) • Patients with underlying lung disease (n=3) • Patients presenting only spontaneous pneumomediastinum (n=5) • Guidelines, case series with Studies included heterogeneous populations, review Included (n=36) of all pleural
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