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Spontaneous pneumothorax is an uncommon complication of COVID-19 viral pneumonia. The exact incidence and risk factors are still unknown. Herein we review the incidence and outcomes of pneumothorax in over 3000 patients admitted to our institution for suspected COVID-19 pneumonia. We performed a retrospective review of COVID-19 cases admitted to our hospital. Patients who were diagnosed with a spontaneous pneumothorax were identified to calculate the incidence of this event. Their clinical characteristics were thoroughly documented. Data regarding their clinical outcomes were gathered. Each case was presented as a brief synopsis. Three thousand three hundred sixty-eight patients were admitted to our institution between March 1st, 2020 and June 8th, 2020 for suspected COVID 19 pneumonia, 902 patients were nasopharyngeal swab positive. Six cases of COVID-19 patients who developed spontaneous pneumothorax were identified (0.66%). Their baseline imaging showed diffuse bilateral ground-glass opacities and consolidations, mostly in the posterior and peripheral lung regions. 4/6 cases were associated with mechanical ventilation. All patients required placement of a chest tube. In all cases, mortality (66.6%) was not directly related to the pneumothorax. Spontaneous pneumothorax is a rare complication of COVID-19 viral pneumonia and may occur in the absence of mechanical ventilation. Clinicians should be vigilant about the diagnosis and treatment of this complication.

Introduction: The annual report for the National Audit of Cardiac Rhythm Management (CRM) Devices describes procedural activity and complication rates; it is reported through the National Institute of Cardiovascular Outcomes Research (NICOR). NICOR sets a cut off of 15 months following implant to attribute device related complications. However, device related revisions can occur after 15 months and we sought to investigate these and compare them with the NICOR group. Methods: Our devices database was searched for all device procedures during 2018, and all recorded complications. A comparison was made between patients within, and outside of the 15-month reporting period. Complications were classified as wound related, infection, pneumothorax, haematoma, lead displacement and ‘other’ lead complications such as parameter changes or integrity faults. The time from the first device implant to detection of complication was recorded, however some patients underwent further procedures within this period. Statistical analysis was performed with Chi-squared and t-test. Results: 2,393 CRM device procedures were performed at our centre over 2018. A total of 174 (7.28%) complications were recorded, involving 169 patients. 115 (4.81%) complications were recorded across 110 patients, within the 15-month NICOR period, and 59 (2.47%) occurred after 15 months. NICOR mean age was higher than the non-NICOR group (69.8 ± 16.5 versus 63.8 ± 19.0 years, p=0.04) but the proportion of males was similar (57.3 versus 64.4%, p=0.37). All-cause mortality was similar 5five (4.5%) versus 3 (5.1%), p=0.88. As the data was dichotomised by time from implant, mean time from first implant to recorded complication was shorter in the NICOR group compared with the non-NICOR group (1.48 ± 3.09 versus 9.89 ± 5.89 years, p<0.0001). Within the NICOR group (n=115), lead displacements made up the largest proportion, 45 (39.12%), followed by ‘other’ lead complications 16 (13.91%), wound revisions 16 (13.91%), infection 13 (11.30%), pneumothorax 5 (4.35%), haematoma 9 (7.83%) and pericardial effusion 6 (5.22%). By contrast, the non-NICOR complications (n=59) were dominated by ‘other’ lead complications, 37 (61.71%) which primarily related to integrity issues and parameter changes. There was 1 lead displacement beyond 15 months (1.69%), 8 (13.56%) wound revisions and 12 (20.34%) very late infections. There were no reported pneumothoraxes, haematomas or pericardial effusions after 15 months. Discussion: A considerable proportion of complications requiring intervention present many years after the initial implant, and certainly outside of the NICOR reporting window. Although reported locally, this may reflect a significant burden of morbidity related to CRM devices that goes unreported at a national level. Conclusion: Late device related complications falling outside of the NICOR reporting window are an important source of patient comorbidity and they deserve our attention and further investigation. [Image Omitted]

Pneumothorax represents a common clinical problem. An overview of relevant and updated information on epidemiology, pathophysiology, and management of spontaneous (primary and secondary), catamenial, and traumatic (iatrogenic and noniatrogenic) pneumothorax is given.

In the coronavirus disease 2019 (COVID-19) era, the presence of acute respiratory failure is generally associated with acute respiratory distress syndrome; however, it is essential to consider other differential diagnoses that require different, and urgent, therapeutic approaches. Herein we describe a COVID-19 case complicated with bilateral spontaneous pneumothorax. A previously healthy 45-year-old man was admitted to our emergency department with sudden-onset chest pain and progressive shortness of breath 17 days after diagnosis with uncomplicated COVID-19 infection. He was tachypneic and presented severe hypoxemia (75% percutaneous oxygen saturation). Breath sounds were diminished bilaterally on auscultation. A chest X-ray revealed the presence of a large bilateral pneumothorax. A thoracic computed tomography (CT) scan confirmed the large bilateral pneumothorax, with findings consistent with severe COVID-19 infection. Chest tubes were inserted, with immediate clinical improvement. Follow-up chest CT scan revealed resolution of bilateral pneumothorax, reduction of parenchymal consolidation, and formation of large bilateral pneumatoceles. The patient remained under observation and was then discharged home. Bilateral spontaneous pneumothorax is a very rare, potentially life-threatening complication in patients with COVID-19. This case highlights the importance of recognizing this complication early to prevent potentially fatal consequences.

The implantation cardiac rhythm management devices is rising annually. The two known common complications of these devices, infection and pneumothorax, occur in 1.2% and 0.6% of patients, respectively. Pneumothorax is usually seen in the ipsilateral part of implantation however in some rare cases this will be seen in the contralateral part. Despite using cephalic vein cutdown or venogram assisted puncture of axillary vein to reduce this complication, pneumothorax remains the one of the most morbid complications post implant. In this article a rare case of bilateral pneumothorax will be presented and discussed.

Spontaneous pneumothorax associated with tuberculosis due to clinical manifestations, imaging findings and negative pleural biopsy is rare. A 43-year-old young woman went to the hospital several times because of recurrent dyspnea and was diagnosed with a right spontaneous pneumothorax. She underwent multiple closed thoracic drainage procedures, but the pneumothorax was not completely resolved. Pleural biopsy pathology was chronic inflammation; there was no evidence of tuberculosis. A small amount of pneumothorax persisted, intermittent dyspnea became more severe, and pneumothorax increased. Bronchoscopy showed thickening of the left lung lingular segment mucosa, and the bronchial lavage fluid gene X-PERT/rifampicin resistance test was positive. After one month of anti-tuberculosis treatment, the symptoms of short breath were completely relieved, and chest computerized tomography (CT) showed complete resolution of the right pneumothorax. When searching for the cause of spontaneous pneumothorax, people should not overlook tuberculosis-related secondary pneumothorax, which should be diagnosed and treated as soon as possible.

Background: Primary spontaneous pneumothorax is managed initially with observation and chest tube placement, followed by surgical intervention in select cases. With little currently published evidence, the role of surgical pleurodesis or pleurectomy to reduce primary spontaneous pneumothorax recurrence remains unclear. This study compares the recurrence rates of primary spontaneous pneumothorax following bullectomy alone versus bullectomy with pleurodesis or pleurectomy. Methods: A retrospective review was performed at a quaternary hospital for all patients undergoing surgery for primary spontaneous pneumothorax between June 2006 and December 2018. Patient demographic characteristics, disease severity, operative technique and time between initial surgery and recurrence were recorded. Standard statistical techniques were used for univariable and multivariable analyses. Results: Of 222 total included patients, 28 required a second surgery: 4 (1.8%) for prolonged air leak and 24 (10.8%) for recurrent pneumothorax. The median time from first to second surgery was 363 days and 35.7% of recurrences did not present until after 2 years. Age, sex, smoking, year of initial surgery, disease severity and surgical technique did not significantly affect recurrence rate on univariable analysis. On multivariable analysis, the odds ratios of recurrence for bullectomy with mechanical pleurodesis or pleurectomy were 0.82 and 0.15, respectively (p = 0.22), compared with bullectomy alone. Combined bullectomy, pleurectomy and pleurodesis had the lowest recurrence rate (0/18, 0%). Conclusion: Bullectomy with pleurectomy and pleurodesis demonstrated a 0% recurrence rate for the treatment of primary spontaneous pneumothorax in this study. Statistical significance was not achieved in univariable or multivariable analyses comparing recurrence rates for the surgical approaches. A multicentre randomized controlled trial with longer follow-up than previously performed is needed to confirm these preliminary findings and optimize surgical management of primary spontaneous pneumothorax.

We sought to determine the rate and risk factors of recurrent spontaneous pneumothorax in a diverse population. Cohort study using the California Public Discharge Data file (1995–2010). We identified patients with first-time spontaneous pneumothorax. The primary outcome was recurrent pneumothorax. Associations with clinical, patient, and hospital characteristics were assessed using Cox regression analysis. Among 14,609 patients with a first-time episode of spontaneous pneumothorax, 26.2% developed a recurrence. Risk factors included age <35 (Hazard Ratio [HR] 1.24 95%-Confidence Interval [CI] 1.14–1.36), Asian race (HR 1.24, CI 1.13–1.37), and tube thoracostomy (HR 1.2, CI 1.15–1.31). Mechancial pleurodesis (HR 0.37 CI 0.31–0.45) was superior to chemical pleurodesis (HR 0.71 CI 0.58–0.86) in reducing recurrence risk. The risk of recurrent pneumothorax is greatest in patients age <35, Asians, and those requiring a tube thoracostomy. The risks of operative intervention should be balanced against patient risk for recurrence. Population analysis of recurrent spontaneous pneumothorax in California (1995–2010). [Display omitted] •Risk of recurrence after spontaneous pneumothorax is 26.2%.•Greatest risk of recurrence is within 2 years.•Age <35 and prior tube thoracostomy are at highest risk for recurrence.•Mechanical pleurodesis associated with greatest reduction in recurrence.

In Germany, 10,000 cases of spontaneous pneumothorax are treated inpatient every year. The German Society for Thoracic Surgery, in co-operation with the German Society for Pulmonology, the German Radiological Society, and the German Society of Internal Medicine has developed an S3 guideline on spontaneous pneumothorax and post-interventional pneumothorax moderated by the German Association of Scientific Medical Societies. Method: Based on the source guideline of the British Thoracic Society (2010) for spontaneous pneumothorax, a literature search on spontaneous pneumothorax was carried out from 2008 onwards, for post-interventional pneumothorax from 1960 onwards. Evidence levels according to the Oxford Center for Evidence-Based Medicine (2011) were assigned to the relevant studies found. Recommendations according to grade (A: “we recommend”/“we do not recommend,” B: “we suggest”/“we do not suggest”) were determined in 3 consensus conferences by the nominal group process. Results: The algorithms for primary and secondary pneumothorax differ in the indication for CT scan as well as in the indication for chest drainage application and video-assisted thoracic surgery. Indication for surgery is recommended individually taking into account the risk of recurrence, life circumstances, patient preferences, and procedure risks. For some forms of secondary pneumothorax, a reserved indication for surgery is recommended. Therapy of post-interventional spontaneous pneumothorax is similar to that of primary spontaneous pneumothorax. Discussion: The recommendations of the S3 Guideline provide assistance in managing spontaneous pneumothorax and post-interventional pneumothorax. Whether this will affect existing deviant diagnostic and therapeutic measures will be demonstrated by future epidemiological studies.

More than 250 patients with uncomplicated, primary spontaneous pneumothorax were treated conservatively or by pleural intervention. In a complete-case analysis, reexpansion within 8 weeks occurred in 98.5% of the patients in the intervention group and in 94.4% of those in the conservative-management group.