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 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 4  |  Page : 250-251

Point-of-care lung ultrasound and early detection of pneumothorax in a COVID-19–positive patient undergoing noninvasive ventilation therapy

1 Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission18-Dec-2020
Date of Acceptance02-Sep-2021
Date of Web Publication24-Dec-2021

Correspondence Address:
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune - 411 040, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_168_20

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How to cite this article:
Dwivedi D, Bhan S, Paul D, Hooda B. Point-of-care lung ultrasound and early detection of pneumothorax in a COVID-19–positive patient undergoing noninvasive ventilation therapy. Int J Acad Med 2021;7:250-1

How to cite this URL:
Dwivedi D, Bhan S, Paul D, Hooda B. Point-of-care lung ultrasound and early detection of pneumothorax in a COVID-19–positive patient undergoing noninvasive ventilation therapy. Int J Acad Med [serial online] 2021 [cited 2023 Jun 5];7:250-1. Available from: https://www.ijam-web.org/text.asp?2021/7/4/250/333408

To the Editor,

Noninvasive ventilation (NIV) therapy during the COVID-19 pandemic has been recommended for mild-to-moderate acute hypoxemic respiratory failure and has shown a favorable result in lowering the mortality and the incidence of intubation in such subsets of patients.[1] Spontaneous pneumothorax, although rare, is reported to occur in 1% of the cases of COVID-19 patients.[2] Incidence of barotrauma due to invasive ventilation in these patients can be as high as 15%.[3]

We present a 65-year-old COVID-positive woman weighing 54 kg, a nonsmoker with no comorbidity. She developed unilateral, right pneumothorax while being treated for acute hypoxemic respiratory failure by NIV with a face mask for the past 5 days. The therapy was bridged alternatively with high-flow nasal oxygen therapy (AIRVO 2 Fischer and Paykel). The patient, while on NIV therapy, was on a pressure support of 6 cm of H2O with positive end-expiratory pressure of 8 cm of H2O and was maintaining oxygen saturation above 95% with respiratory rate of 26/min. All of a sudden, the patient became breathless with the oxygen saturation started to drop between 84% and 85%, and she started to pull off her NIV mask from her face. The patient was reassured, and NIV was stopped and was put on high-flow nasal oxygen therapy (AIRVO 2 Fischer and Paykel) with a flow rate of 45 L/min, FiO2 of 0.9, and temperature of 34°C. The patient felt comfortable, with oxygen saturation maintained between 92% and 94%. At this juncture, point-of-care lung ultrasound was done using a linear array probe (7–13 MHZ Sonosite, M-TURBO, FUJIFILM, India). It revealed the absence of the sliding sign over the right chest wall with evidence of “Bar Code Sign” on M Mode [Figure 1], indicating toward the right-sided pneumothorax, which was also confirmed by the portable bedside X-ray chest [Figure 2]. Immediate action was taken, and under strict asepsis, tube thoracostomy was done with 14 Fr chest tube on the right side, with the egress of air, it was connected to the water seal drainage.
Figure 1: Lung ultrasound demonstrating “barcode sign” indicating pneumothorax

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Figure 2: Chest X-ray anterior-posterior view of a COVID-positive patient, showing right pneumothorax marked with an arrow with mediastinal shift and left side of the lung with diffuse ground-glass opacities

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COVID-19 patients with increased surge of inflammatory mediators are known to inflict lung parenchyma adversely, resulting in the damage of the alveoli with consequent air leaks.[2] Spontaneous pneumothorax due to altered lung morphology and barotrauma related to mechanical ventilation is explained in the literature.[2],[3] However, caution has to be undertaken in prompt diagnosis of the pneumothorax in these patients on various ventilation strategies as it may lead to tension pneumothorax if remained undetected. NIV-induced pneumothorax in this patient could be explained by excessive tidal volumes (TVs) generated with the transmission of the high transpulmonary pressures to the distal diseased airways. TV delivered to the patient during NIV therapy with facemask depends on both the pressure support generating the airway pressure and the pressure generated by the patient's self-respiratory drive, resulting in higher TV in the wake of increased respiratory effort.[4] Therefore, strict monitoring is required during the NIV trial in these patients with fragile lungs susceptible to injury, and likewise, there is a need to adjust the pressure support and control the respiratory rate to prevent the generation of larger TV.

Boero et al. have recommended wider applicability of lung ultrasound during COVID-19 pandemic, with its role in diagnosing various changes in the lung field with the assessment of progression of the disease and response to the treatment.[5] In addition to the applications mentioned already, incorporation of point-of-care lung ultrasound as per BLUE protocol if done judiciously on every patient on NIV or invasive ventilation will be able to detect complications related to barotrauma such as pneumothorax, thereby preventing the morbidity and mortality related to it.

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Conflicts of interest

There are no conflicts of interest.

Patient consent statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to not require Institutional Review Board/Ethics Committee Review and the corresponding protocol/approval number for being “Letter to Editor.” The authors declare that patient consent was obtained in compliance with CARE guidelines.

  References Top

Singh A. Noninvasive versus invasive ventilation: One modality cannot fit all during COVID-19 outbreak. Korean J Anesthesiol 2020;73:359-60.  Back to cited text no. 1
Mallick T, Dinesh A, Engdahl R, Sabado M. COVID-19 complicated by spontaneous pneumothorax. Cureus 2020;12:e9104.  Back to cited text no. 2
McGuinness G, Zhan C, Rosenberg N, Azour L, Wickstrom M, Mason DM, et al. Increased incidence of barotrauma in patients with COVID-19 infection on invasive mechanical ventilation. Radiology 2020;297:E252-62.  Back to cited text no. 3
Patel BK, Kress JP, Hall JB. Alternatives to invasive ventilation in the COVID-19 pandemic. JAMA 2020;324:43-4.  Back to cited text no. 4
Boero E, Schreiber A, Rovida S, Vetrugno L, Blaivas M. The role of lung ultrasonography in COVID-19 disease management. J Am Coll Emerg Physicians Open 2020;1:1357-63.  Back to cited text no. 5


  [Figure 1], [Figure 2]


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