Discussion:
Pneumothorax is the presence of air in pleural space, which can be
broadly classified as spontaneous and traumatic (7). Spontaneous
pneumothorax not associated with any underlying lung disease is called
primary, and those associated with some underlying lung disease are
categorized as secondary (7). Our patient, who was in the recovery phase
of COVID-19, experienced a spontaneous pneumothorax. Given the
association with COVID-19 pneumonia, this condition was classified as a
secondary spontaneous pneumothorax. The occurrence of pneumothorax in
COVID-19 patients varies, with a range of 0.3% in hospitalized
individuals and a higher prevalence of 12.8% to 23.8% among those who
require mechanical ventilation(8). A study by Chong et al. did not
identify age or active smoking status as a risk factor for
COVID-19-related pneumothorax (8). Our patient smoked one pack of
cigarettes daily and stopped just after he was diagnosed with COVID-19.
Studies have shown the development of subpleural bullae that are visible
on X-ray or CT scans before the occurrence of spontaneous pneumothorax.
However, in our patient, a Chest X-ray (Figure 1b.) performed six days
before the development of pneumothorax didn’t show any subpleural bullae
(2). Interestingly, the pneumothoraces that are caused due to COVID-19
usually tend to be right-sided and unilateral, as seen in our case as
well (8).
Conservative treatment is recommended to manage asymptomatic
pneumothorax, i.e., without significant breathlessness. Simple
aspiration must be performed for symptomatic cases and should be
admitted and observed for at least 24 hours(10). Intercostal drainage is
recommended for those patients who fail to respond with aspiration and
in all cases of secondary pneumothorax. The procedure is, however, not
recommended for asymptomatic secondary pneumothorax or patients with
apical pneumothorax measuring less than 1cm (10). Weissberg et al.
recommend chest tube drainage when pneumothorax occupies more than 20%
of pleural space. In our case, more than 50% of the pleural space on
the right lung was occupied by pneumothorax, which warranted the
placement of a chest tube(11).
However, even with the chest tube in-situ, there was minimal lung
re-expansion, which prompted further investigations to discover the
cause of persistent pneumothorax. An HRCT scan of the lungs showed the
presence of a Bronchopleural Fistula (BPF), an abnormal connection
between a bronchus and pleural space associated with very high morbidity
and mortality. Many factors are related to developing a bronchopleural
fistula, including necrotizing infection of the lungs, persistent
spontaneous pneumothorax, radiotherapy, and chemotherapy(9). Our patient
may have developed the fistula due to persistent spontaneous
pneumothorax. BPF may be associated with empyema of the lungs if it
persists for a long duration, for which chest drainage and long-term
antibiotics are crucial to treatment (6). In our patient, after
visualization of hydropneumothorax on HRCT, surgical consultation was
done to assess the functionality of the previously inserted chest tube
and to manage the BPF surgically. The second chest tube drain was
inserted to give negative suction pressure as the first chest tube was
not functioning correctly. Endobronchial intervention is preferred for
seriously ill patients with small-size fistulas. The endobronchial
intervention included sealing agents like glues, blood patches, or
endobronchial valves. Surgical management is usually indicated for large
bronchopleural fistula measuring more than 8 mm in size or persistent
symptomatic pneumothorax due to the BPF (6). Surgical intervention,
although planned, could not be performed as our patient succumbed to
death due to rapid deterioration, even with appropriate management.