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.