Pneumothorax and Subcutaneous Emphysema
Evaluation in Patients with COVID-19 in the Intensive
Care Unit

Turkyilmaz, Atila; Öksüz Güngör, Burcu; KÜÇÜK, Ahmet Oğuzhan; AYÇIÇEK, OLCAY; OZLÜ, TEVFIK; Öztuna, Funda; PEHLİVANLAR KÜÇÜK, Mehtap; Bulbul, Yilmaz

doi:10.4274/tybd.galenos.2021.30316

Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit

Mehtap PEHLİVANLAR KÜÇÜK, (Karadeniz Technical University Faculty of Medicine, Department of Chest Diseases, Division of Intensive Care Medicine, Trabzon, Turkey)

Burcu ÖKSÜZ GÜNGÖR, (Karadeniz Technical University Faculty of Medicine, Department of Thoracic Surgery, Trabzon, Turkey)

Ahmet Oğuzhan KÜÇÜK, (Karadeniz Technical University Faculty of Medicine, Department of Anesthesiology and Reanimation, Division of Intensive Care Medicine, Trabzon, Turkey)

Olcay AYÇİÇEK, (Karadeniz Technical University Faculty of Medicine, Department of Chest Diseases, Trabzon, Turkey)

Atilla TÜRKYILMAZ, (Karadeniz Technical University Faculty of Medicine, Department of Thoracic Surgery, Trabzon, Turkey)

Funda ÖZTUNA, (Karadeniz Technical University Faculty of Medicine, Department of Chest Diseases, Trabzon, Turkey)

Yılmaz BÜLBÜL, (Karadeniz Technical University Faculty of Medicine, Department of Chest Diseases, Trabzon, Turkey)

Tevfik ÖZLÜ (Karadeniz Technical University Faculty of Medicine, Department of Chest Diseases, Trabzon, Turkey)

Türk Yoğun Bakım Dergisi

2 0

Yıl: 2021 Cilt: 19 Sayı: 1 Sayfa Aralığı: 95 - 101 Metin Dili: İngilizce DOI: 10.4274/tybd.galenos.2021.30316 İndeks Tarihi: 13-06-2022

Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit

Öz:

Objective: Pneumothorax (PNX) and subcutaneous emphysema (SCE) have increased in importance as a frequently occurring complication. This study aimed to reveal the frequency, timing, and possible risk factors in patients with PNX and SCE who are followed up with coronavirus disease-2019 (COVID-19) diagnosis in our tertiary intensive care unit (ICU). Materials and Methods: All patients with confirmed COVID-19 who were followed up and treated in our unit between August 8, 2020, and February 20, 2021, in a 16-bed tertiary ICU and who developed PNX and SCE during their hospitalization were included. Results: PNX and SCE developed in 16 (9.6%) of 165 patients who were followed up in our ICU due to COVID-19. Of these 16 patients, 3 (18.8%) survived. The median age of patients was 66.5 years (interquartile range: 58.5-75.5). Diabetes mellitus was the most common comorbidity in patients with PNX and SCE. Additionally, 12 (75%) patients had a smoking history. Of 15 (93.8%) patients who developed PNX, 4 (25%) were bilateral, and SCE developed in 9 (56.3%) patients. Twelve (75%) patients with PNX and SCE were under invasive mechanical ventilation, 3 (18.8%) under spontaneous breathing, and 1 (6.2%) under non-invasive mechanical ventilation treatment. The number of oxygen support days until the time PNX and SCE developed was 9 (6.25-17) days in the whole group, the median time was 6 days in the survival group and 9 days in the non-survival group. Conclusion: In the COVID-19 pandemic, complications, such as PNX and SCE, are more frequently observed (9.5%) than in the general intensive care population and the later period of intensive care admission (median 9 days). Smoking is defined as a risk factor in most of these patients; however, increased PNX rates are thought to be related to both COVID-19 pneumonia and parenchymal damage due to cytokine storms

Anahtar Kelime:

COVID-19 Tanılı Yoğun Bakım Hastalarında Pnömotoraks ve Subkütan Amfizem Olgularının Değerlendirilmesi

Öz:

Amaç: Koronavirüs hastalığı-2019 (COVID-19) ile takipli yoğun bakım hastalarında pnömotoraks (PNX)/deri altı amfizem (SCE) pandeminin ilk zamanlarında yapılan tanımlamaların aksine sık ortaya çıkan bir komplikasyon olarak önemini artırmaktadır. Bu çalışma ile 3. düzey yoğun bakım ünitemizde (YBÜ) COVID-19 tanısı ile takip edilen PNX/SCE olgularının sıklığını, zamanlamasını ve olası risk faktörlerini ortaya koymak hedeflenmiştir. Gereç ve Yöntem: On altı yataklı 3. düzey YBÜ’de, 28 Ağustos 2020 ve 20 Şubat 2021 arasında ünitemizde takip ve tedavi edilmiş tüm teyitli COVID-19 hastalarından, yatışları sırasında PNX ve SCE gelişen olgular dahil edilmiştir. Bulgular: Hedef tarih aralığında YBÜ’de COVID-19 nedeni ile 165 hasta takip edilmiş olup bu hastaların 16’sında (%9,6) PNX/SCE gelişmiştir. Bu 16 hastanın 4’ü (%25) sağ kalmıştır. Hastaların medyan yaşı 66,5 (çeyrekler açıklığı: 58,5-75,5) idi. PNX/SCE gelişen hastalarda en sık komorbidite diabetes mellitus olarak tespit edildi. Hastaların 12’sinin (%75) sigara kullanım öyküsü mevcuttu. PNX gelişen 15 (%93,8) hastanın 4’ü (%25) bilateraldi. SCE ise 9 (%56,3) hastada gelişti. PNX/ SCE saptanan 12 (%75) hasta invazif mekanik ventilasyon tedavisi altındayken, 3 (%18,8) hasta spontan solunumda, 1 (%6,2) hasta non-invazif mekanik ventilasyon tedavisi altındaydı. PNX/SCE geliştiği ana kadar oksijen desteği verilen gün sayısı tüm grupta 9 (6,25-17) gün iken, sağkalan grupta medyan değer 6 gün, ölen grupta 9 gün idi. Oksijen destek gün süresi ölen grupta yüksek olsa da istatistiksel anlamlı fark saptanmadı (p=0,439). Sonuç: COVID-19 pandemisinde PNX/SCE gibi komplikasyonlar uzun süreli oksijen desteğini takiben genel yoğun bakım popülasyonundan daha sık (%9,5) ve yoğun bakım yatışının daha geç döneminde (medyan 9 gün) gözlenmektedir. Bu hastaların çoğunda bir risk faktörü olarak sigara tanımlansa da PNX oranlarındaki bu artışın hem COVID-19 pnömonisi hem de sitokin fırtınasına bağlı oluşan parankimal hasar ile ilgili olduğunu düşünüyoruz.

Anahtar Kelime:

Belge Türü: Makale Makale Türü: Araştırma Makalesi Erişim Türü: Erişime Açık

1. Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus Disease 2019 (COVID-19): A Systematic Review of Imaging Findings in 919 Patients. AJR Am J Roentgenol 2020;215:87-93.
2. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 2020;323:1061-9.
3. Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.
4. Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol 2020;92:2511-5.
5. Yao W, Wang T, Jiang B, Gao F, Wang L, Zheng H, et al. Emergency tracheal intubation in 202 patients with COVID19 in Wuhan, China: lessons learnt and international expert recommendations. Br J Anaesth 2020;125:e28-e37.
6. Jacobi A, Chung M, Bernheim A, Eber C. Portable chest X-ray in coronavirus disease-19 (COVID-19): A pictorial review. Vol. 64, Clinical Imaging. Elsevier Inc; 2020. p. 35-42.
7. Elhakim TS, Abdul HS, Pelaez Romero C, Rodriguez-Fuentes Y. Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in COVID-19 pneumonia: a rare case and literature review. BMJ Case Rep 2020;13:e239489.
8. Alhakeem A, Khan MM, Al Soub H, Yousaf Z. Case Report: COVID-19- Associated Bilateral Spontaneous Pneumothorax-A Literature Review. Am J Trop Med Hyg 2020;103:1162-5.
9. de Lassence A, Timsit JF, Tafflet M, Azoulay E, Jamali S, Vincent F, et al. Pneumothorax in the intensive care unit: incidence, risk factors, and outcome. Anesthesiology 2006;104:5-13.
10. Lew TW, Kwek TK, Tai D, Earnest A, Loo S, Singh K, et al. Acute respiratory distress syndrome in critically ill patients with severe acute respiratory syndrome. JAMA 2003;290:374-80.
11. Fowler RA, Lapinsky SE, Hallett D, Detsky AS, Sibbald WJ, Slutsky AS, et al. Critically ill patients with severe acute respiratory syndrome. JAMA 2003;290:367-73.
12. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395:507-13.
13. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a singlecentered, retrospective, observational study. Lancet Respir Med 2020;8:475- 81.
14. George B, Megally M, Mrejen-Shakin K. Spontaneous pneumothorax and spontaneous pneumomediastinum in non-intubated patients in the setting of Severe Acute Respiratory Syndrome Coronavirus 2. Chest 2020;158:A1653-4.
15. Muhammad AI, Boynton EJ, Naureen S. COVID-19 with bilateral pneumothoraces- case report. Respir Med Case Rep 2020;31:101254.
16. Talan L, Şaşal Solmaz FG, Ercan U, Akdemir Kalkan İ, Yenigün BM, Yüksel C, et al. COVID-19 pneumonia and pneumothorax: case series. Tuberk Toraks 2020;68:437-43.
17. Vahapoğlu A, Akpolat B, Çavuş Z, Genç Moralar D, Türkmen A. Spontaneous Hemopneumothorax During the Course of COVID-19 Pneumonia. Turkish J Intensive Care 2020;18:46-9.
18. Lichtenstein D, Mezière G, Biderman P, Gepner A. The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26:1434-40.
19. Lichtenstein DA, Lascols N, Prin S, Mezière G. The “lung pulse”: an early ultrasound sign of complete atelectasis. Intensive Care Med 2003;29:2187-92.
20. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19) Intensive Care Med 2020;46:854-87.
21. Özdemir S, Bilgi DÖ, Köse S, Oya G. Pneumothorax in patients with coronavirus disease 2019 pneumonia with invasive mechanical ventilation. Interact Cardiovasc Thorac Surg 2021;32:351-5.
22. Guven BB, Erturk T, Kompe Ö, Ersoy A. Serious complications in COVID19 ARDS cases: pneumothorax, pneumomediastinum, subcutaneous emphysema and haemothorax. Epidemiol Infect 2021;149:e137.
23. EVMS COVID-19 Management protocol An overview of the MATH+ and I-MASK+ Protocols. 2020.
24. Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Epidemiology of pneumothorax in England. Thorax 2000;55:666-71.
25. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000;342:868-74.
26. Comroe JH, Dripps RD, Dumke PR, Deming M. Oxygen toxicity: The effect of inhalation of high concentrations of oxygen for twenty-four hours on normal men at sea level and at a simulated altitude of 18,000 feet. J Am Med Assoc 1945;128:710-7.
27. Sackner MA, Landa J, Hirsch J, Zapata A. Pulmonary effects of oxygen breathing. A 6-hour study in normal men. Ann Intern Med 1975;82:40-3.
28. Carpagnano GE, Kharitonov SA, FoschinoBarbaro MP, Resta O, Gramiccioni E, Barnes PJ. Supplementary oxygen in healthy subjects and those with COPD increases oxidative stress and airway inflammation. Thorax 2004;59:1016-9.
29. Mantell LL, Lee PJ. Signal transduction pathways in hyperoxia-induced lung cell death. Mol Genet Metab 2000;71:359- 70.
30. Zhang C, Wu Z, Li JW, Zhao H, Wang GQ. Cytokine release syndrome in severe COVID-19: interleukin-6 receptor antagonist tocilizumab may be the key to reduce mortality. Int J Antimicrob Agents 2020;55:105954.
31. Marini JJ, Gattinoni L. Management of COVID-19 Respiratory Distress. JAMA 2020;323:2329-30.

APA	PEHLİVANLAR KÜÇÜK M, Öksüz Güngör B, KÜÇÜK A, AYÇIÇEK O, Turkyilmaz A, Öztuna F, Bulbul Y, OZLÜ T (2021). Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. , 95 - 101. 10.4274/tybd.galenos.2021.30316
Chicago	PEHLİVANLAR KÜÇÜK Mehtap,Öksüz Güngör Burcu,KÜÇÜK Ahmet Oğuzhan,AYÇIÇEK OLCAY,Turkyilmaz Atila,Öztuna Funda,Bulbul Yilmaz,OZLÜ TEVFIK Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. (2021): 95 - 101. 10.4274/tybd.galenos.2021.30316
MLA	PEHLİVANLAR KÜÇÜK Mehtap,Öksüz Güngör Burcu,KÜÇÜK Ahmet Oğuzhan,AYÇIÇEK OLCAY,Turkyilmaz Atila,Öztuna Funda,Bulbul Yilmaz,OZLÜ TEVFIK Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. , 2021, ss.95 - 101. 10.4274/tybd.galenos.2021.30316
AMA	PEHLİVANLAR KÜÇÜK M,Öksüz Güngör B,KÜÇÜK A,AYÇIÇEK O,Turkyilmaz A,Öztuna F,Bulbul Y,OZLÜ T Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. . 2021; 95 - 101. 10.4274/tybd.galenos.2021.30316
Vancouver	PEHLİVANLAR KÜÇÜK M,Öksüz Güngör B,KÜÇÜK A,AYÇIÇEK O,Turkyilmaz A,Öztuna F,Bulbul Y,OZLÜ T Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. . 2021; 95 - 101. 10.4274/tybd.galenos.2021.30316
IEEE	PEHLİVANLAR KÜÇÜK M,Öksüz Güngör B,KÜÇÜK A,AYÇIÇEK O,Turkyilmaz A,Öztuna F,Bulbul Y,OZLÜ T "Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit." , ss.95 - 101, 2021. 10.4274/tybd.galenos.2021.30316
ISNAD	PEHLİVANLAR KÜÇÜK, Mehtap vd. "Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit". (2021), 95-101. https://doi.org/10.4274/tybd.galenos.2021.30316

APA	PEHLİVANLAR KÜÇÜK M, Öksüz Güngör B, KÜÇÜK A, AYÇIÇEK O, Turkyilmaz A, Öztuna F, Bulbul Y, OZLÜ T (2021). Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. Türk Yoğun Bakım Dergisi, 19(1), 95 - 101. 10.4274/tybd.galenos.2021.30316
Chicago	PEHLİVANLAR KÜÇÜK Mehtap,Öksüz Güngör Burcu,KÜÇÜK Ahmet Oğuzhan,AYÇIÇEK OLCAY,Turkyilmaz Atila,Öztuna Funda,Bulbul Yilmaz,OZLÜ TEVFIK Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. Türk Yoğun Bakım Dergisi 19, no.1 (2021): 95 - 101. 10.4274/tybd.galenos.2021.30316
MLA	PEHLİVANLAR KÜÇÜK Mehtap,Öksüz Güngör Burcu,KÜÇÜK Ahmet Oğuzhan,AYÇIÇEK OLCAY,Turkyilmaz Atila,Öztuna Funda,Bulbul Yilmaz,OZLÜ TEVFIK Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. Türk Yoğun Bakım Dergisi, vol.19, no.1, 2021, ss.95 - 101. 10.4274/tybd.galenos.2021.30316
AMA	PEHLİVANLAR KÜÇÜK M,Öksüz Güngör B,KÜÇÜK A,AYÇIÇEK O,Turkyilmaz A,Öztuna F,Bulbul Y,OZLÜ T Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. Türk Yoğun Bakım Dergisi. 2021; 19(1): 95 - 101. 10.4274/tybd.galenos.2021.30316
Vancouver	PEHLİVANLAR KÜÇÜK M,Öksüz Güngör B,KÜÇÜK A,AYÇIÇEK O,Turkyilmaz A,Öztuna F,Bulbul Y,OZLÜ T Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit. Türk Yoğun Bakım Dergisi. 2021; 19(1): 95 - 101. 10.4274/tybd.galenos.2021.30316
IEEE	PEHLİVANLAR KÜÇÜK M,Öksüz Güngör B,KÜÇÜK A,AYÇIÇEK O,Turkyilmaz A,Öztuna F,Bulbul Y,OZLÜ T "Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit." Türk Yoğun Bakım Dergisi, 19, ss.95 - 101, 2021. 10.4274/tybd.galenos.2021.30316
ISNAD	PEHLİVANLAR KÜÇÜK, Mehtap vd. "Pneumothorax and Subcutaneous Emphysema Evaluation in Patients with COVID-19 in the Intensive Care Unit". Türk Yoğun Bakım Dergisi 19/1 (2021), 95-101. https://doi.org/10.4274/tybd.galenos.2021.30316