• Users Online: 702
  • Print this page
  • Email this page

 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 217-221

Acute respiratory distress syndrome and pneumothorax in COVID-19 patients

1 Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Anesthesiology and Critical Care Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Research Center for Health Management in Mass Gathering, Red Crescent Society of the Islamic Republic of Iran, Tehran, Iran
4 Oxford International Development Group, Oxford, Mississippi, USA

Date of Submission24-Apr-2021
Date of Acceptance22-May-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Seyed Mohammad Reza Hashemian
Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_62_21

Rights and Permissions

Background: Spontaneous pneumothorax is known as a fatal complication in patients with COVID-19. However, the exact pathogenesis of the spontaneous pneumothorax occurrence and its cause remains unknown. Accordingly, the present study examined 30 patients with acute COVID-19-induced respiratory failure who were under biphasic positive airway pressure (BIPAP) and medical ventilator machines. Methods: This study is a retrospective study and was performed on patients with COVID-19-induced acute respiratory failure who were admitted to the intensive care unit. The study population included 30 patients (10 patients with pneumothorax complication and 20 other patients without this complication). All study patient demographic data and device parameters (physiological parameters observed by the device) were collected and compared with each other. Results: Overall, 30 patients with COVID-19 and acute respiratory distress syndrome (ARDS) were selected during the 3 months from April to July 2020, with complications of spontaneous pneumothorax and emphysema detected in the collected chest X-ray images of 10 patients. In general, the results showed that p-plateau and p-peak parameters in the group with pneumothorax were significantly higher than the other group. Alternately, it was observed that static compliance for the group with pneumothorax was significantly lower than the uncomplicated group. Further, the mortality rates obtained were equal to 80% for the group with pneumothorax complication and 55% for the other group. Conclusion: Spontaneous pneumothorax in patients with ARDS and COVID-19 is a rare complication with a high mortality rate that occurs even in patients without intubation and patients undergoing BIPAP. Hence, if low static compliance and high pulmonary pressures are observed for patients, physicians should seek the complication diagnosis and treatment following changes in patients' symptoms.

Keywords: Acute respiratory distress syndrome, COVID-19, pneumothorax, spontaneous

How to cite this article:
Hashemian SM, Shafigh N, Erfani R, Khoundabi B, Miller J. Acute respiratory distress syndrome and pneumothorax in COVID-19 patients. Biomed Biotechnol Res J 2021;5:217-21

How to cite this URL:
Hashemian SM, Shafigh N, Erfani R, Khoundabi B, Miller J. Acute respiratory distress syndrome and pneumothorax in COVID-19 patients. Biomed Biotechnol Res J [serial online] 2021 [cited 2022 May 17];5:217-21. Available from: https://www.bmbtrj.org/text.asp?2021/5/2/217/318438

  Introduction Top

Since last year, the COVID-19 pandemic has been prevalent around the world and caused multiple complications and symptoms.[1] One of the rare complications of this disease is spontaneous pneumothorax, in which late diagnosis leads to increased mortality in patients. Pneumothorax is very deadly in patients with acute respiratory failure due to COVID-19. Thus, early diagnosis of this complication is critically important.[2] Pneumothorax may cause unusual and few symptoms in these patients, while late diagnosis can result in tension pneumothorax to develop and cause severe hemodynamic disorders.[3]

Despite limited and scattered studies on this subject, the incidence rate of this complication has not yet been determined. On the other hand, only a few studies have reviewed several case reports and stated that pneumothorax increases patient mortality.[4] In one study, it also was reported that the cause of pneumothorax in these patients is probably due to cystic and fibrotic changes in the lungs, which ultimately leads to increased pulmonary pressures in these patients.[5],[6]

In general, as studies on spontaneous pneumothorax in patients with COVID-19 are limited, this study investigates and compares the obtained demographic data, device parameters, and mortality rates of patients with pneumothorax complication (10 patients) and patients without this complication (20 patients).

  Methods Top

The present study is a retrospective study. In this study from April to July 2020, 30 patients hospitalized due to COVID-19 (with positive nasal polymerase chain reaction testing) were examined in the intensive care unit (ICU) of the Masih Daneshvari Hospital. Ten patients with spontaneous pneumothorax underwent chest tube. Furthermore, all patients were computed tomography (CT) scanned at the time of admission, and their chests were imaged as symptoms changed. In addition, patients with pneumothorax symptoms underwent chest tube implantation. In general, in this study, pulmonary parameters and information related to age, sex, and weight of patients were performed to diagnose the risk of spontaneous pneumothorax. Information on weight, sex, age, C-reactive protein (CRP), interleukin-6 (IL-6), data related to ventilator, and biphasic positive airway pressure (BIPAP) also were recorded for all patients. It should be noted that during the present study, the presence of pneumothorax and death was connected after a few days of patient hospitalization. Ethics approval: Ethical approval was obtained from the National Research Institute of Tuberculosis scientific Ethics Committee with the date and number 01/02/2020-1048.

Statistical analysis

The data were analyzed using the statistical package IBM SPSS version 24.0 and descriptive statistics (the Statistical Package for the Social Sciences, Chicago, IL, USA). The categorical variables are expressed as proportions and frequencies. Kolmogorov–Smirnov test is used to test normality of continuous variable. The normal continuous variables are summarized as means and standard deviations and nonnormal are shown by median and interquartile range. T-test and Mann–Whitney U-test are used to compare mean/median between two groups. P < 0.05 was considered as statistically significant.

  Results Top

The results indicated that among the study population, 10 patients had shown pneumothorax and the others (20 patients) without this complication. Furthermore, it was observed that 6 patients (60%) with pneumothorax and 12 patients of the control group (60%) were male.

The mean weight of patients with pneumothorax group was calculated 85 kg, while it was assessed equal to 78.5 kg for the control group.

In addition to the above, primary pulmonary symptoms (pulmonary involvement rate) in the first CT lung scanning in pneumothorax and control groups were estimated equal to 75.5 and 65.5, respectively, which were performed at the time of patients' admission into the ICU. It should be noted that six patients of the pneumothorax group had ventilated with noninvasive BIPAP.

The results also showed that p-plateau value and static compliance were obtained, respectively, equal to 34.8 and 15 in the pneumothorax group and equal to 28 and 27.5 in the control group.

  Discussion Top

The COVID-19 disease can cause acute respiratory failure, which can lead to pneumothorax with impaired pulmonary parenchyma and increased intrathoracic pressure.[6] Our findings showed that increased turbidity and pulmonary involvement on CT scan and chest X-ray increased the possibility of pneumothorax. Furthermore, it was observed that increasing the intensity of CRP and IL-6 leads to an increased risk of pneumothorax. In addition, the results showed that men and obese people were more likely to have pneumothorax than women and lean people [Table 1]. Zantah et al. attributed structural changes in the lung parenchyma to pneumothorax in patients with COVID-19, which causes cystic and fibrotic changes, such that increased intrathoracic pressure due to prolonged cough and mechanical ventilation rupture. These cysts and pneumothorax.[3] It also has been stated that since high-pressure driving increases pneumothorax, it is very important to pay attention to this parameter for patients with acute respiratory distress syndrome.[7]
Table 1: Comparison characteristics between two groups

Click here to view

In the present study, pulmonary parameters, such as p-plateau, positive end-expiratory pressure, and p-peak, were evaluated in 10 patients with pneumothorax, and the results showed that p-plateau and p-peak in the group with pneumothorax were significantly higher than the control group (at P < 0.05). On the other hand, static compliance in this group was significantly lower than in another group [Figure 1].
Figure 1: Box plots of variables with significant difference between two groups

Click here to view

Furthermore, the involvement of the CT scan in patients with pneumothorax was significantly higher than the control group at the time of admission into the ICU (P value; P = 0.006) [Figure 1], [Figure 2], [Figure 3], [Figure 4].
Figure 2: Tension pneumothorax

Click here to view
Figure 3: Emphysema and pneumothorax

Click here to view
Figure 4: Pneumomediastinum and emphysema

Click here to view

In a study, Ferreira et al. mentioned pneumothorax as a late complication in patients with severe pulmonary involvement.[8]

In the present study, the complication of pneumothorax was investigated in patients undergoing BIPAP and ventilator, and it seems that invasive and noninvasive mechanical ventilation is a risk factor for pneumothorax.

Furthermore, in the group of patients with pneumothorax, six patients were undergoing BIPAP St mode.

Eperjesiova et al. also mentioned mechanical ventilation as an important factor in pneumothorax.[9]

The study performed by Gidaro et al. reported cases of pneumothorax in the NI in patients with COVID-19.[10] However, pneumothorax has also been reported in patients who have not undergone mechanical ventilation. For example, a case report of pneumomediastinum was investigated in an elderly COVID-19 patient with a nonmechatronic respiratory system in the study conducted by Kong et al.[11]

Apparently, early imaging and CT scans of the lungs can help doctors, and researchers predict pneumothorax [Figure 2], [Figure 3], [Figure 4]. Liu et al. showed a case of a COVID-19 patient who had a cystic lesion on its CT scan.[12]

In our study, patients who had more pulmonary involvement at the time of admission to the ICU were significantly more likely to develop pneumothorax [Table 1]. Therefore, it seems that early CT scans and daily images can prevent pneumothorax [Figure 2], [Figure 3], [Figure 4].

Zantah et al. recommended early CT and daily chest X-rays.[3] Giamarellos et al., concerning the increase of inflammatory factors in patients with pulmonary involvement, stated that increasing factors of CRP and IL6 were associated with increased pulmonary involvement and pulmonary complications.[13] Our findings also revealed that IL6 and CRP were higher in the pneumothorax group than in the control group [Table 1] and [Figure 2], [Figure 3], [Figure 4].

  Conclusion Top

Pneumothorax seems to be a notable dangerous complication in patients with COVID-19 that its incidence can lead to increased mortality. Therefore, performing early CT scans, continuous chest radiograph (CXR), and IL6 and CRP tests can predict it, save many patients, and assist physicians in treating these patients.

Financial support and sponsorship

This study was financially supported by National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Masih Daneshvary hospital, Tehran, Iran.

Conflicts of interest

There are no conflicts of interest.

  References Top

Wang W, Gao R, Zheng Y, Jiang L. COVID-19 with spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema. J Travel Med 2020;27:taaa062.  Back to cited text no. 1
Quincho-Lopez A, Quincho-Lopez DL, Hurtado-Medina FD. Case report: Pneumothorax and pneumomediastinum as uncommon complications of COVID-19 pneumonia-literature review. Am J Trop Med Hyg 2020;103:1170-6.  Back to cited text no. 2
Zantah M, Dominguez Castillo E, Townsend R, Dikengil F, Criner GJ. Pneumothorax in COVID-19 disease – Incidence and clinical characteristics. Respir Res 2020;21:236.  Back to cited text no. 3
Spiro JE, Sisovic S, Ockert B, Böcker W, Siebenbürger G. Secondary tension pneumothorax in a COVID-19 pneumonia patient: A case report. Infection 2020;48:941-4.  Back to cited text no. 4
Fahad AM, Mohammad AA, Al-Khalidi HA, Alshewered AS. Spontaneous pneumothorax as a complication in COVID-19 male patient: A case report. Clin Case Rep 2020;8:3116-9.  Back to cited text no. 5
Zhou C, Gao C, Xie Y, Xu M. COVID-19 with spontaneous pneumomediastinum. Lancet Infect Dis 2020;20:510.  Back to cited text no. 6
Tonetti T, Vasques F, Rapetti F, Maiolo G, Collino F, Romitti F, et al. Driving pressure and mechanical power: New targets for VILI prevention. Ann Transl Med 2017;5:286.  Back to cited text no. 7
Ferreira JG, Rapparini C, Gomes BM, Pinto LAC, Freire MS. Pneumothorax as a late complication of COVID-19. Rev Inst Med Trop Sao Paulo 2020;62:e61.  Back to cited text no. 8
Eperjesiova B, Hart E, Shokr M, Sinha P, Ferguson GT. Spontaneous pneumomediastinum/pneumothorax in patients with COVID-19. Cureus 2020;12:e8996.  Back to cited text no. 9
Gidaro Antonio, Samartin Federica, Anna M. Brambilla, Cogliati Chiara, Ingrassia Stella, Banfi Francesco et al. Occurrence of Pneumothorax and Pneumomediastinum in Covid-19 patients during non-invasive ventilation with Continuous Positive Airway Pressure. doi: https://doi.org/10.1101/2020.08.31.20185348.  Back to cited text no. 10
Kong N, Gao C, Xu MS, Xie YL, Zhou CY. Spontaneous pneumomediastinum in an elderly COVID-19 patient: A case report. World J Clin Cases 2020;8:3573-7.  Back to cited text no. 11
Liu K, Zeng Y, Xie P, Ye X, Xu G, Liu J, et al. COVID-19 with cystic features on computed tomography: A case report. Medicine (Baltimore) 2020;99:e20175.  Back to cited text no. 12
Giamarellos-Bourboulis EJ, Netea MG, Rovina N, Akinosoglou K, Antoniadou A, Antonakos N, et al. Complex Immune dysregulation in COVID-19 patients with severe respiratory failure. Cell Host Microbe 2020;27:992-1000.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded89    
    Comments [Add]    

Recommend this journal