key: cord-304248-sxbyxnxn
authors: Aiolfi, Alberto; Biraghi, Tullio; Montisci, Andrea; Bonitta, Gianluca; Micheletto, Giancarlo; Donatelli, Francesco; Cirri, Silvia; Bona, Davide
title: MANAGEMENT OF PERSISTENT PNEUMOTHORAX WITH THORACOSCOPY AND BLEBS RESECTION IN COVID-19 PATIENTS
date: 2020-04-27
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.04.011
sha: 
doc_id: 304248
cord_uid: sxbyxnxn

Abstract Several studies have been published describing the clinical and radiographic findings on the novel coronavirus (COVID-19) pneumonia. Therefore, there is currently a lack of pathologic data about its effects in intubated patients. Pneumothorax may occur rarely and results from a combination of fibrotic parenchyma with prolonged high-pressure ventilation. Chest drain represent the first line treatment. However, in case of persistent pneumothorax, thoracoscopy and bleb resection may be a feasible option to reduce air leak and improve ventilation. We report the cases of two COVID-19 patients successfully treated with thoracoscopy, bleb resection, and pleurectomy for persistent pneumothorax.

Histologic data describing the pathologic changes of lung parenchyma caused by the COVID-19 are scarce [1] . A recent report showed edema, proteinaceous exudate, focal reactive hyperplasia of pneumocytes with patchy inflammatory cellular infiltration, and multinucleated giant cells [2] . This thickened, stiff tissue makes difficult for lungs to work properly and sustainedpressure ventilation may be necessary to obtain acceptable gas exchanges. In this setting, fibrotic parenchyma and pre-existing emphysematous blebs are prone to rupture with consequent risk of pneumothorax. Chest drains may be required however, in case of persistent air leak minimally invasive thoracoscopy with blebs resection may be indicated.

A 56-year old active smoker man was admitted to our hospital for fever, cough, and respiratory Both procedures were performed bed-side in the ICU department with non-selective low tidal volume ventilation. A 28 Fr chest tube was placed at the end of the procedure. On POD 1 there was no residual air leak and the chest X-ray did not show evidence of residual pneumothorax in both cases. Drains were removed on POD 2.

Reports on imaging findings of COVID-19 patients are now emerging [3] . The largest case series described multilobar involvement and rounded peripheral GGO while pneumothorax is rarely described as presentation sign (1%) [4] . Iatrogenic pneumothorax related to mechanical ventilation is a potentially lethal complication reported in up to 15% of ventilated patients [5] . It has been shown that iatrogenic pneumothorax occurs mostly in patients with an underlying lung diseases (i.e. COPD, ARDS, etc.) during the early phase of intubation [6] . As described for ARDS, lungs of COVID-19 patients with significant interstitial involvement, seem physiologically small with low compliance and reduced elastance. This seems to be supported by recent pathologic findings showing edema, proteinaceous exudates, vascular congestion, and inflammatory changes [1] .

Therefore, overinflation and high PEEP in such fibrotic and hypoelastic lungs may cause alveolar or pre-existing blebs rupture.

Iatrogenic pneumothorax in intubated COVID-19 patients is uncommon but may be seen with the progression of disease [3] . While chest tube placement should be considered as first line treatment, the persistence of air leak may constitute indication for low tidal volume two-lung ventilation thoracoscopy [7] [8] . The procedure timing is unclear and was discussed multidisciplinary. In the first case, after chest tube placement, a wait-and-see strategy was preferred because doubts about the real effectiveness of the procedure. In the second case, a more aggressive and earlier operative attempt was planned. Although the procedure was successful in both, because the feeling of a stiffer parenchyma black cartridges were used for resection in the first case. Hence, we believe that early indication for thoracoscopy may be presumably better because the less traumatized, fibrotic, and inflamed interstitial tissues.

To the best of our knowledge, this is the first report that describes two COVID-19 patients treated with thoracoscopy and blebs resection for persistent pneumothorax. Treatment of pneumothorax in these patients is uncertain. While chest tube drainage seems indicated as first step treatment, thoracoscopy may be warranted in case of persistent or recurrent pneumothoraces.

Timing of minimally invasive treatment is unclear, therefore early indication may presumably result in better outcomes and more effective air leak control. 

Clinical Characteristics of Coronavirus Disease 2019 in China

Pulmonary Pathology of Early-Phase 2019 Novel Coronavirus (COVID-19) Pneumonia in Two Patients with Lung Cancer

Coronavirus Disease 2019 (COVID-19): A Systematic Review of Imaging Findings in 919 Patients

Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study

Iatrogenic pneumothorax: etiology and morbidity. Results of a Department of Veterans Affairs Cooperative Study

Iatrogenic pneumothorax related to mechanical ventilation

Advances in thoracostomy tube management

Thoracoscopic bleb resection using two-lung ventilation anesthesia with low tidal volume for primary spontaneous pneumothorax