Yoğun bakım ünitesinde COVID-19 pnömonisi olan hastalarda pnömotoraks: kötü prognozun bir göstergesi

Abstract

Amaç: Bu çalışmanın amacı, koronavirüs hastalığı 2019 (COVID-19) pnömonisi nedeniyle yoğun bakım ünitesinde (YBÜ) yatan hastalarda pnömotoraks insidansı ve gelişiminin hasta prognozu ile ilişkili olup olmadığını araştırmaktır. Yöntemler: Bu retrospektif, kohort, tanımlayıcı çalışma etik kurul onayının ardından başlatıldı. Çalışma, Mart 2020 ile Mart 2022 arasında üçüncü basamak YBÜ'ye yatırılan doğrulanmış COVID-19 pnömonisi olan hastalar üzerinde yürütüldü. Veriler hasta kayıt sisteminden ve YBÜ dosyalarından toplandı. Hastalar pnömotoraks gelişenler ve gelişmeyenler olmak üzere iki gruba ayrıldı. YBÜ'deki mortalite ile ilişkili faktörler tek değişkenli analiz ve çoklu lojistik regresyon analizi ile değerlendirildi. Bulgular: Çalışmaya Mart 2020 ile Mart 2022 arasında YBÜ'ye yatırılan doğrulanmış COVID-19 enfeksiyonu ve pnömonisi olan toplam 397 hasta dahil edildi. Hastaların yaş ortalaması 62 ± 15 yıl idi. Hastaların %56,1'i erkekti. Hastaların %6,8'inde pnömotoraks tespit edildi. Pnömotoraksa ek olarak altı hastada (%1,5) pnömomediastinum görüldü. Toplam hasta popülasyonunda mortalite oranı %40,5 idi. Pnömotorakslı grupta mortalite oranı %81,5, pnömotorakssız grupta ise %37,6 olarak bulundu. Pnömotoraks tanısından sonra mortaliteye kadar geçen medyan süre 6 gündü (aralığı 1-29 gün). Pnömotoraks tek başına YBÜ'de mortaliteyi yedi kat, diğer değişkenler hesaba katıldığında ise iki kat arttırdı. Sonuç: Pnömotoraks, koruyucu ventilasyon stratejilerinin kullanılmasına rağmen YBÜ'de COVID-19 pnömonisi olan hastalarda mortaliteyi etkileyen yaygın ve ölümcül bir komplikasyondur. YBÜ'de solunum desteği alan hastalarda ve şiddetli inflamatuar yanıtı olan hastalarda özellikle dikkat edilmelidir.

Keywords

• pnömotoraks
• pnömomediastinum
• yoğun bakım ünitesi
• prognoz
• COVID-19

Pneumothorax in patients with COVID-19 pneumonia in the intensive care unit: an indicator of poor prognosis

Abstract

Aims: The objective of this study was to investigate whether the incidence and development of pneumothorax in patients hospitalized in the intensive care unit (ICU) with coronavirus disease 2019 (COVID-19) pneumonia is associated with patient prognosis. Methods: This retrospective, cohort, descriptive study was initiated following approval from the ethics committee. The study was conducted on patients with confirmed COVID-19 pneumonia admitted to the tertiary ICU between March 2020 and March 2022. Data were collected from the patient registry system and ICU files. The patients were divided into two groups: those who developed pneumothorax and those who did not. The factors associated with mortality in the ICU were evaluated by univariate analysis and multiple logistic regression analysis. Results: The study included a total of 397 patients with confirmed cases of COVID-19 infection and pneumonia who were admitted to the ICU between March 2020 and March 2022. The mean age of the patients was 62±15 years. Of the patients, 56.1% were male. Pneumothorax was identified in 6.8% of patients. In addition to pneumothorax, six patients (1.5%) exhibited pneumomediastinum. The mortality rate was observed to be 40.5% among the total patient population. The mortality rate was 81.5% in the group with pneumothorax and 37.6% in the group without pneumothorax. The median time to mortality was 6 days (range 1–29 days) following the diagnosis of pneumothorax. Pneumothorax alone increased the likelihood of mortality in the ICU sevenfold (OR 7.3, 95% CI=2.70–19.75) and twofold when other variables were taken into account (OR 2, 95% CI=0.57-6.99). Conclusion: Pneumothorax is a common and fatal complication affecting mortality in patients with COVID-19 pneumonia in the ICU, despite the use of protective ventilation strategies. Particular caution should be exercised in patients receiving respiratory support in the ICU and in patients with a severe inflammatory response.

Keywords

• Pneumothorax
• pneumomediastinum
• intensive care unit
• prognosis
• COVID-19

References

1. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges. Int J Antimicrob Agents. 2020;55(3):1-9. doi:10.1016/j.ijantimicag.2020.105924
2. Parpucu ÜM, Turan S, Dal HC, et al. Which factors are predicting the mortality in patients with COVID-19 in the intensive care unit? J Med Palliat Care. 2021;4(4):368-372. doi:10.47582/jompac.1333211
3. Uysal E, Seğmen F, Ulubaşoğlu P, Zengin EN, Erdem D. The progress of chronic renal disease patients followed by the diagnosis of COVID-19 in ICU. J Health Sci Med. 2022;5(5):1443-1448. doi:10.32322/jhsm.1152051
4. Sağlam E, Savaş A, Öke D, Özlü C, Koçar B, Erkalp K. Intensive care unit: mortality score in early prediction of mortality in critical COVID-19 patients. J Med Palliat Care. 2023;4(5):572-578. doi:10.47582/jompac.1346978
5. Organization WH. WHO global research and innovation forum to mobilize international action in response to the novel coronavirus (2019-nCoV) emergency. WHO. Accessed 11-12 Feb 2020, 2020. https://www.who.int/news-room/events/detail/2020/02/11/default-calendar/global-research-and-innovation-forum-to-mobilize-international-action-in-response-to-the-novel-coronavirus-(2019-ncov)-emergency
6. Ai T, Yang Z, Hou H, et al. Correlation of chest CT and RT-PCR testing for coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases. Radiology. 2020;296(2):32-40. doi:10.1148/radiol.2020200642
7. Carotti M, Salaffi F, Sarzi-Puttini P, et al. Chest CT features of coronavirus disease 2019 (COVID-19) pneumonia: key points for radiologists. Radiol Med. 2020;125(7):636-646. doi:10.1007/s11547-020-01237-4
8. Kwee TC, Kwee RM. Chest CT in COVID-19: what the radiologist needs to know. Radiographics. 2020;40(7):1848-1865. doi:10.1148/rg.219015

9. Caruso D, Polidori T, Guido G, et al. Typical and atypical COVID-19 computed tomography findings. World J Clin Cases. 2020;8(15):3177-3187. doi:10.12998/wjcc.v8.i15.3177
10. Kommoss FKF, Schwab C, Tavernar L, et al. The pathology of severe COVID-19-related lung damage. Dtsch Arztebl Int. 2020;117(29-30): 500-506. doi:10.3238/arztebl.2020.0500
11. Joynt GM, Antonio GE, Lam P, et al. Late-stage adult respiratory distress syndrome caused by severe acute respiratory syndrome: abnormal findings at thin-section CT. Radiology. 2004;230(2):339-346. doi:10.1148/radiol.2303030894
12. Liu K, Zeng Y, Xie P, et al. COVID-19 with cystic features on computed tomography: a case report. Medicine. 2020;99(18):1-3. doi:10.1097/MD. 0000000000020175
13. Sun R, Liu H, Wang X. Mediastinal emphysema, giant bulla, and pneumothorax developed during the course of COVID-19 pneumonia. Korean J Radiol. 2020;21(5):541-544. doi:10.3348/kjr.2020.0180
14. Manna S, Maron SZ, Cedillo MA, et al. Spontaneous subcutaneous emphysema and pneumomediastinum in non-intubated patients with COVID-19. Clin Imaging. 2020;67:207-213. doi:10.1016/j.clinimag.2020. 08.013
15. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(2):18-31. doi:10.1136/thx.2010.136986
16. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-513. doi:10.1016/S0140-6736(20)30211-7
17. Jamous F, Meyer N, Buus D, et al. Critical illness due to COVID-19: a description of the surge in a single center in sioux falls. S D Med. 2020; 73(7):312-317.
18. Yao W, Wang T, Jiang B, et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations. Br J Anaesth. 2020;125(1):28-37. doi:10.1016/j.bja.2020.03.026
19. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol. 2020;92(11):2511-2515. doi:10.1002/jmv. 25891
20. Angeles C, Magharious P, Cvetkovic D, Weigel T. The answer to the silent "super spreader": an innovative way to manage chest drains on coronavirus patients with active air leaks. A A Pract. 2021;15(3):1-3. doi: 10.1213/XAA.0000000000001419
21. Ulutas H, Celik MR, Gulcek I, et al. Management of spontaneous pneumothorax in patients with COVID-19. Interact Cardiovasc Thorac Surg. 2022;34(6):1002-1010. doi:10.1093/icvts/ivab280
22. Das KM, Lee EY, Al Jawder SE, et al. Acute middle east respiratory syndrome coronavirus: temporal lung changes observed on the chest radiographs of 55 patients. AJR Am J Roentgenol. 2015;205(3):267-274. doi:10.2214/AJR.15.14445
23. Wang XH, Duan J, Han X, et al. High incidence and mortality of pneumothorax in critically Ill patients with COVID-19. Heart Lung. 2021;50(1):37-43. doi:10.1016/j.hrtlng.2020.10.002
24. Park SJ, Park JY, Jung J, Park SY. Clinical manifestations of spontaneous pneumomediastinum. Korean J Thorac Cardiovasc Surg. 2016;49(4):287-291. doi:10.5090/kjtcs.2016.49.4.287
25. Desai SR. Acute respiratory distress syndrome: imaging of the injured lung. Clin Radiol. 2002;57(1):8-17. doi:10.1053/crad.2001.0889
26. Barton LM, Duval EJ, Stroberg E, Ghosh S, Mukhopadhyay S. COVID-19 autopsies, Oklahoma, USA. Am J Clin Pathol. 2020;153(6):725-733. doi: 10.1093/ajcp/aqaa070
27. Wichmann D. Autopsy findings and venous thromboembolism in patients with COVID-19. Ann Intern Med. 2020;173(12):1. doi:10.7326/L20-1206
28. Sihoe AD, Wong RH, Lee AT, et al. Severe acute respiratory syndrome complicated by spontaneous pneumothorax. Chest. 2004;125(6):2345-2351. doi:10.1378/chest.125.6.2345
29. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. Jama. 2010;303(9):865-873. doi:10.1001/jama.2010.218
30. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020; 8(5):475-481. doi:10.1016/S2213-2600(20)30079-5
31. 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(3):1170-1176. doi:10.4269/ajtmh.20-0815
32. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000; 342(12):868-874. doi:10.1056/NEJM200003233421207
33. Sahni S, Verma S, Grullon J, Esquire A, Patel P, Talwar A. Spontaneous pneumomediastinum: time for consensus. N Am J Med Sci. 2013;5(8): 460-464. doi:10.4103/1947-2714.117296
34. López Vega JM, Parra Gordo ML, Diez Tascón A, Ossaba Vélez S. Pneumomediastinum and spontaneous pneumothorax as an extrapulmonary complication of COVID-19 disease. Emerg Radiol. 2020;27(6):727-730. doi:10.1007/s10140-020-01806-0
35. Pieracci FM, Burlew CC, Spain D, et al. Tube thoracostomy during the COVID-19 pandemic: guidance and recommendations from the AAST acute care surgery and critical care committees. Trauma Surg Acute Care Open. 2020;5(1):1-4. doi:10.1136/tsaco-2020-000498
36. Ershadi R, Rafieian S, Salehi M, et al. COVID-19 and spontaneous pneumothorax: a survival analysis. J Cardiothorac Surg. 2023;18(1):1-9. doi:10.1186/s13019-023-02331-0
37. Satici C, Demirkol MA, Sargin Altunok E, et al. Performance of pneumonia severity index and CURB-65 in predicting 30-day mortality in patients with COVID-19. Int J Infect Dis. 2020;98:84-89. doi:10.1016/j.ijid.2020.06.038
38. Aiolfi A, Biraghi T, Montisci A, et al. Management of persistent pneumothorax with thoracoscopy and bleb resection in COVID-19 patients. Ann Thorac Surg. 2020;110(5):413-415. doi:10.1016/j.athoracsur. 2020.04.011
39. Qin C, Zhou L, Hu Z, et al. Dysregulation of immune response in patients with coronavirus 2019 (COVID-19) in Wuhan, China. Clin Infect Dis. 2020;71(15):762-768. doi:10.1093/cid/ciaa248
40. Ye Q, Wang B, Mao J. The pathogenesis and treatment of the `Cytokine Storm' in COVID-19. J Infect. 2020;80(6):607-613. doi:10.1016/j.jinf. 2020.03.037