An 88-year-old woman diagnosed with COVID-19 at a hospital in Sao Paulo - the epicenter of the COVID-19 outbreak in Brazil - was put under mechanical ventilation for 20 days due to acute respiratory distress syndrome (ARDS) caused by the SARS-CoV-2.
The patient had no history of smoking. Laboratory examination revealed a high percentage of white blood cell neutrophil count 12,870 (normal range: 1700-7000 mm3) and a decreased percentage lymphocyte count 860 (normal range: 900-2900 mm3). There were elevated blood levels for C-reactive protein 28.05 mg/L (normal range: 0-5 mg/L), D-dimer 4.65 mg/L (normal range: < 0.5 mg/L), and Lactic Dehydrogenase (LDH) 595 U/L (normal range: 240-480 U/L). At a fraction of inspired O2 (FiO2) of 60%, with a PEEP of 8 mmHg under a 20 mmHg pressure support, the blood gas analysis showed pH 7.49 (normal 7.35-7.45) a PO2 of 89 mmHg (normal 80-100 mmHg), pCO2 of 28 mmHg (normal 35-45 mmHg) and a SatO 2 of 97% (normal 94-100%).
Suddenly, she developed oxygen desaturation (SpO 2) of 87% and a worse respiratory pattern. During physical examination, respiratory sounds were diminished at right hemithorax. The chest x-ray revealed right pneumothorax (Fig. 1-A). A pigtail catheter was introduced with successful reexpansion of the right lung (Fig. 1-B). A huge air escape was observed after the pleural drainage, which was put under a water seal with a filter protected.
Forty-eight hours after the first pneumothorax, the patient developed another respiratory distress, with an ipsilateral new pneumothorax (Fig. 1-C) requiring another chest drain with conventional 28F chest tube thoracostomy under suction, leading to improved lung reexpansion (Fig. 1-D).
The pigtail was withdrawn two days after the chest tube insertion, and the chest tube was kept in place until mechanical ventilation weaning, which occurred 14 days after the second procedure.