A recent letter in the European Respiratory Journal by Marciniak et al., has provided an update on pneumothorax in COVID-19 (1). The authors analysed data from the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK). This encompassed the first and second wave of COVID-19 in the UK and enrolled 131,679 patients over the age of 18 admitted to hospital with COVID-19. Overall, 0.97% had a pneumothorax at some point during their hospital admission, which is in line with their previous estimate of 0.91% (2). The incidence of pneumothorax was not statistically different between the first and second waves, however there was a marked difference in the incidence between groups of patients who received different levels of respiratory support. Of patients requiring no oxygen, 0.16% had a pneumothorax, this increased to 0.56% for patients requiring oxygen support, 0.96% for patients requiring non-invasive respiratory support and 6.1% for patients who required invasive ventilation.
The authors also analysed whether receiving dexamethasone treatment impacted the incidence of pneumothorax, as a small study from Italy had suggested that there was an increased incidence of pneumothorax in patients who had received dexamethasone (3). Importantly, Marciniak et al., found no association of dexamethasone with increased risk of pneumothorax. There was however an increased risk of pneumothorax for those with ‘chronic pulmonary disease’ (e.g. chronic obstructive pulmonary disease) in non-critical care wards, but this didn’t translate to critical care patients.
The most serious finding from this study was that having a pneumothorax with COVID-19 was associated with a worse prognosis, and an increased mortality rate. However, there are several limitations to the study which the authors discussed. Importantly, it was not known if the pneumothorax occurred after ventilation, or if the pneumothorax resulted in the need for ventilation and so the authors were unable to determine if the incidence of pneumothorax in ventilated patients reflects the severity of the disease or is a result of medical intervention.
The authors state that the risk factors identified for pneumothorax in COVID-19 are smoking, male sex, chronic pulmonary disease and invasive ventilation. They do not discuss people who are already at risk of pneumothorax and what this means for them. At the BHD Foundation, we felt this was an important study to share with the BHD community but we fully understand that this information may cause concern and anxiety. We have therefore contacted the lead author of the paper, Professor Stefan Marciniak to ask him some specific questions about the work and what it means for BHD patients.
As an expert on pneumothorax what have you seen in your clinic during the Covid-19 pandemic?
In my pneumothorax clinic I have over 500 individuals who previously suffered pneumothoraces from a variety of causes including cystic lung diseases. None appears to have suffered a recurrence due to COVID-19, although I don’t know how many contracted the illness. Having a family history of pneumothorax does increase the risk of recurrence (although this is not specific to BHD patients as the numbers are too small to confirm this). Overall, lifetime recurrence risk for pneumothorax is about 45% for all patients, and seems similar for BHD; however, it’s uncommon for a recurrence to be attributable to infection or strenuous activity.
How does BHD compare to other cystic lung diseases in terms of risk of severe Covid-19/worse prognosis?
Most of my patients with BHD have largely normal lung tissue on CT, so I don’t consider them to have “significant underlying lung disease”. I haven’t advised my pneumothorax patients to shield unless they have significant underlying lung disease e.g. at least moderate COPD.
Do BHD patients who have more significant lung manifestations have an increased risk of worse prognosis?
This is a very difficult question because there aren’t longitudinal studies in which patients have been followed for many years with a diagnosis of BHD. Surprisingly, it isn’t clear if cysts (the most common feature of BHD in the lung) change over one’s life. It is relatively uncommon for BHD patients to have very severe cystic lung disease, although I have seen this rarely in older patients, so it isn’t possible to give a definitive answer.
Are BHD patients who have had an intervention for pneumothoraces (e.g. pleurodesis) more vulnerable to infection with SARS-CoV-2?
Again, I don’t have data to support or refute this, but I can’t think of a plausible mechanism by which prior surgery would render someone more vulnerable. On the contrary, pleurodesis should make COVID-19 pneumothorax less likely.
Finally, what would your advice be to anyone who may be more vulnerable to infection or worse prognosis upon infection?
Vaccination is safe and highly effective. I would strongly recommend that anyone at risk of COVID-19 should accept vaccination if offered. There is much disinformation about vaccines on social media and the internet, so if people are hesitant or worried, they should discuss the pros and cons of vaccination with their doctor or read the NHS information pages: https://www.nhs.uk/conditions/coronavirus-covid-19/coronavirus-vaccination/coronavirus-vaccine/
We thank Stefan for his time in answering our questions and hope that this reassures the BHD community. If you do have any further questions regarding this study then please email us at firstname.lastname@example.org. Additionally, Stefan will be discussing BHD and pneumothorax in our next
Meet the Experts session which is happening this Wednesday 23rd June. You can sign up for the event here, and a recording of the session will be posted on our website afterwards.
1. Marciniak SJ, Farrell J, Rostron A, Smith I, Openshaw PJM, Baillie JK, et al. COVID-19 Pneumothorax in the United Kingdom: a prospective observational study using the ISARIC WHO clinical characterisation protocol. Eur Respir J [Internet]. 2021 Jun 3 [cited 2021 Jun 17];2100929. Available from: http://erj.ersjournals.com/lookup/doi/10.1183/13993003.00929-2021
2. Martinelli AW, Ingle T, Newman J, Nadeem I, Jackson K, Lane ND, et al. COVID-19 and pneumothorax: A multicentre retrospective case series. Eur Respir J [Internet]. 2020 Sep 9 [cited 2021 Jun 17];56(5). Available from: https://doi.org/10.1183/13993003.02697-2020
3. Palumbo D, Campochiaro C, Belletti A, Marinosci A, Dagna L, Zangrillo A, et al. Pneumothorax/pneumomediastinum in non-intubated COVID-19 patients: Differences between first and second Italian pandemic wave [Internet]. Vol. 88, European Journal of Internal Medicine. Elsevier B.V.; 2021 [cited 2021 Jun 17]. p. 144–6. Available from: https://doi.org/10.1016/j.ejim.2021.03.018