A 48-year-old male with hypertension and hyperlipidemia without a history of cigarette smoking presented to the emergency (ED) with one week of a worsening dry cough associated with chest pain, headaches, myalgia, shortness of breath, and subjective fevers. A chest computed tomography (CT) showed bilateral ground glass opacities (Figure 1A). Laboratory workup showed white blood cell count of 9,000 /µL, c-reactive protein 8.66, creatinine 1.32 mg/dL, and procalcitonin 0.14 mg/dL. The next day he was confirmed COVID positive. He soon developed acute respiratory insufficiency, required intubation, and was transferred to the intensive care unit. Ventilatory settings were PEEP 16 cm H2O, tidal volume (VT) 6 mL/kg, and target plateau pressure 30-55 cm H2O. His FiO2 was weaned to 40% and on hospital day 4 his chest x-ray (CXR) showed extensive subcutaneous emphysema and bilateral tiny apical pneumothoraces (Figure 1B). The PEEP was then decreased to 14. A follow up CXR showed worsening pneumomediastinum and subcutaneous emphysema, but no definite pneumothorax. The next day he required a PEEP of 16, but never redeveloped a pneumothorax for the remainder of his hospital course. He eventually received a tracheostomy and has since been weaned from the ventilator. His tracheostomy tube has been downsized and over 3 months later chest x-rays showed no pneumothorax.
A 76-year-old male presented to the ED with shortness of breath and excessive dry coughing. The patient had tested positive for COVID-19 three days prior but was sent home to recover. Over the course of those three days, the patient got progressively worse, with decreased O2 saturations and increased work of breathing. He also began to have worsening cough and persistent fevers while at home. Upon return to the ED, he was severely hypoxic with increased work of breathing and required intubation within 36 hours of presentation. Treatment was initiated with azithromycin, hydroxychloroquine, zinc, tocilizumab, and dexamethasone for his COVID-19 infection. His hospital course was complicated by septic shock, acute respiratory distress syndrome (ARDS), volume overload, and uncontrolled diabetes. The patient had been intubated and on ventilator support for 21 days when a chest x-ray revealed bilateral pneumothoraces, which were confirmed with a chest CT, along with pneumomediastinum (Figure 2). The patient was transferred to a hospital where thoracic surgery was available and imaging after transfer showed the pneumothorax had slightly increased without tension physiology. The PEEP was decreased from 8 to 6 cm H20 where it remained for the duration of the hospital course. The next day follow up chest x-rays showed resolution of pneumothoraces. On hospital day 31 CXR continued to show no pneumothorax, however the patient passed away from hypoxic respiratory failure later that day.
This is a 68-year-old male who was exposed to a family member who was COVID-19 positive. He began complaining of fevers, cough and dizziness several days prior to presentation to the ED. He was hospitalized for workup of pre-syncope and was confirmed COVID-19 positive. His respiratory status declined and on hospital day 3 he was transferred to the ICU and intubated. Over the next 21 days the patient failed two extubation attempts secondary to hypercapnia and hypoxia. In addition, one failed extubation led to an aspiration event leading to superimposed aspiration pneumonia. The ventilator was set to pressure control of 37 cm H20 with a PEEP of 0, and never changed throughout the hospital course. A right internal jugular dialysis catheter was replaced on hospital day 28 with no pneumothorax seen on post-CXR. Three days later a small right-sided pneumothorax was noted on CXR (Figure 3A) and thoracic surgery was consulted. Due to a stable clinical status, expectant management was pursued. A repeat x-ray 8 hours later showed the pneumothorax was stable. Three days later the patient decompensated from a respiratory standpoint and a chest x-ray that morning showed resolution of the pneumothorax (figure 3B). An hour later the patient died from hypoxic respiratory failure secondary to ARDS.
This patient is a 76-year-old female who presented to the emergency department with altered mental status, hypotension, suspected GI bleed with severe anemia, and sepsis of unknown origin. She was positive for COVID-19 pneumonia and became acutely hypoxic on hospital day 3, requiring emergent intubation. The hospital course was complicated by septic shock leading to multi organ system failure. Throughout her hospital course she continued to require vasopressor support and was ventilator dependent. Her ventilator support requirements remained stable and approximately three weeks into her hospital course she was found to have extensive clinical left sided subcutaneous emphysema. This prompted a CXR revealing a left small to moderate basilar pneumothorax with diffuse subcutaneous emphysema (Figure 4A). The PEEP was decreased from 10 to 5 cm H20 in the following 24 hours and expectant management was pursued. Sequential X-rays showed pneumothorax stability and two days later follow up chest x-ray identified an additional small right sided apical pneumothorax (Figure 4B). Despite the decrease in vent settings, she was unable to be completely weaned from the ventilator. She had persistent tiny apical pneumothoraces until 11 days after the initial pneumothorax when CXR showed resolution of her pneumothoraces with unchanged subcutaneous emphysema. Her hospital course was complicated by renal failure and septic shock due to Staph aureus and E. coli pneumonia which required multiple vasopressors. She gradually became less stable and due to her prognosis, a family meeting was held to make the patient comfort measures only. She expired 21 days after initial pneumothorax seen with no evidence of redevelopment.