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• W3104014378 abstract "BackgroundRecent reports of patients with coronavirus disease 2019 (COVID-19) developing pneumothorax correspond mainly to case reports describing mechanically ventilated patients. The real incidence, clinical characteristics, and outcome of spontaneous pneumothorax (SP) as a form of COVID-19 presentation remain to be defined.Research QuestionDo the incidence, risk factors, clinical characteristics, and outcomes of SP in patients with COVID-19 attending EDs differ compared with COVID-19 patients without SP and non-COVID-19 patients with SP?Study Design and MethodsThis case-control study retrospectively reviewed all patients with COVID-19 diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs) and compared them with two control groups: COVID-19 patients without SP and non-COVID-19 patients with SP. The relative frequencies of SP were estimated in COVID-19 and non-COVID-19 patients in the ED, and annual standardized incidences were estimated for both populations. Comparisons between case subjects and control subjects included 52 clinical, analytical, and radiologic characteristics and four outcomes.ResultsWe identified 40 occurrences of SP in 71,904 patients with COVID-19 attending EDs (0.56‰; 95% CI, 0.40‰-0.76‰). This relative frequency was higher than that among non-COVID-19 patients (387 of 1,358,134, 0.28‰; 95% CI, 0.26‰-0.32‰; OR, 1.93; 95% CI, 1.41-2.71). The standardized incidence of SP was also higher in patients with COVID-19 (34.2 vs 8.2/100,000/year; OR, 4.19; 95% CI, 3.64-4.81). Compared with COVID-19 patients without SP, COVID-19 patients developing SP more frequently had dyspnea and chest pain, low pulse oximetry readings, tachypnea, and increased leukocyte count. Compared with non-COVID-19 patients with SP, case subjects differed in 19 clinical variables, the most prominent being a higher frequency of dysgeusia/anosmia, headache, diarrhea, fever, and lymphopenia (all with OR > 10). All the outcomes measured, including in-hospital death, were worse in case subjects than in both control groups.InterpretationSP as a form of COVID-19 presentation at the ED is unusual (< 1‰ cases) but is more frequent than in the non-COVID-19 population and could be associated with worse outcomes than SP in non-COVID-19 patients and COVID-19 patients without SP. Recent reports of patients with coronavirus disease 2019 (COVID-19) developing pneumothorax correspond mainly to case reports describing mechanically ventilated patients. The real incidence, clinical characteristics, and outcome of spontaneous pneumothorax (SP) as a form of COVID-19 presentation remain to be defined. Do the incidence, risk factors, clinical characteristics, and outcomes of SP in patients with COVID-19 attending EDs differ compared with COVID-19 patients without SP and non-COVID-19 patients with SP? This case-control study retrospectively reviewed all patients with COVID-19 diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs) and compared them with two control groups: COVID-19 patients without SP and non-COVID-19 patients with SP. The relative frequencies of SP were estimated in COVID-19 and non-COVID-19 patients in the ED, and annual standardized incidences were estimated for both populations. Comparisons between case subjects and control subjects included 52 clinical, analytical, and radiologic characteristics and four outcomes. We identified 40 occurrences of SP in 71,904 patients with COVID-19 attending EDs (0.56‰; 95% CI, 0.40‰-0.76‰). This relative frequency was higher than that among non-COVID-19 patients (387 of 1,358,134, 0.28‰; 95% CI, 0.26‰-0.32‰; OR, 1.93; 95% CI, 1.41-2.71). The standardized incidence of SP was also higher in patients with COVID-19 (34.2 vs 8.2/100,000/year; OR, 4.19; 95% CI, 3.64-4.81). Compared with COVID-19 patients without SP, COVID-19 patients developing SP more frequently had dyspnea and chest pain, low pulse oximetry readings, tachypnea, and increased leukocyte count. Compared with non-COVID-19 patients with SP, case subjects differed in 19 clinical variables, the most prominent being a higher frequency of dysgeusia/anosmia, headache, diarrhea, fever, and lymphopenia (all with OR > 10). All the outcomes measured, including in-hospital death, were worse in case subjects than in both control groups. SP as a form of COVID-19 presentation at the ED is unusual (< 1‰ cases) but is more frequent than in the non-COVID-19 population and could be associated with worse outcomes than SP in non-COVID-19 patients and COVID-19 patients without SP. Infection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) is characterized mainly by fever and respiratory symptoms, with dyspnea and lung infiltrates being present in more than 50% of hospitalized cases.1Guan W.J. Ni Z.Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (19386) Google Scholar A significant number of other signs and symptoms can be present, involving the GI tract, hepatic inflammation, myalgia and rhabdomyolysis, neurologic symptoms such as dysgeusia and anosmia, or a procoagulant state, biochemically detected by increased D-dimers and related to complications and worse prognosis.1Guan W.J. Ni Z.Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (19386) Google Scholar, 2Chen N. Zhou M. Dong X. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (13646) Google Scholar, 3Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 323(20):2052-2059.Google Scholar, 4Lodigiani C. Iapichino G. Carenzo L. et al.Humanitas COVID-19 Task ForceVenous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy.Thromb Res. 2020; 191: 9-14Abstract Full Text Full Text PDF PubMed Scopus (1432) Google Scholar In some patients, some of these entities appear after the patient has been admitted and, to some extent, represent the increased number of complications that may be presented by patients who are bedridden, multidrug treated, and/or in very poor condition. In this scenario, it is difficult to quantify the real association of a certain manifestation with the pathogenesis of the disease caused by SARS-CoV-2 infection. Spontaneous pneumothorax (SP) is a potential complication in some pulmonary infections, and it is especially frequent in Pneumocystis jirovecii pneumonia.5Rivero A. Perez-Camacho I. Lozano F. et al.Etiology of spontaneous pneumothorax in 105 HIV-infected patients without highly active antiretroviral therapy.Eur J Radiol. 2009; 71: 264-268Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The real incidence of SP in patients with coronavirus disease 2019 (COVID-19) is currently unknown. Some sporadic cases of patients with COVID-19 developing pneumothorax have been reported.2Chen N. Zhou M. Dong X. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (13646) Google Scholar,6Liu K. Zeng Y. Xie P. et al.COVID-19 with cystic features on computed tomography: a case report.Medicine (Baltimore). 2020; 99e20175Crossref PubMed Scopus (84) Google Scholar, 7Wang W. Gao R. Zheng Y. Jiang L. COVID-19 with spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema.J Travel Med. 2020; 27taaa062Crossref PubMed Scopus (44) Google Scholar, 8Wang J. Su X. Zhang T. Zheng C. Spontaneous pneumomediastinum: a probable unusual complication of coronavirus disease 2019 (COVID-19) pneumonia.Korean J Radiol. 2020; 21: 627-628Crossref PubMed Scopus (65) Google Scholar, 9Aiolfi A. Biraghi T. Montisci A. et al.Management of persistent pneumothorax with thoracoscopy and bleb resection in COVID-19 patients.Ann Thorac Surg. 2020; 110: e413-e415Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 10Sun R. Liu H. Wang X. Mediastinal emphysema, giant bulla, and pneumothorax developed during the course of COVID-19 pneumonia.Korean J Radiol. 2020; 21: 541-544Crossref PubMed Scopus (206) Google Scholar, 11López Zúñiga M.A. López Zúñiga D. Martínez Colmenero J. Rodríguez Sánchez A. Gutiérrez Lara G. López Ruz M.A. Spontaneous mediastinal emphysema in patients with COVID-19.Emergencias. 2020; 32: 298-299PubMed Google Scholar, 12Janssen M.L. van Manen M.J.G. Cretier S.E. Braunstahl G.J. Pneumothorax in patients with prior or current COVID-19 pneumonia.Respir Med Case Rep. 2020; 31: 101187PubMed Google Scholar, 13Volpi S. Ali J.M. Suleman A. Ahmed R.N. Pneumomediastinum in COVID-19 patients: a case series of a rare complication.Eur J Cardiothorac Surg. 2020; 58: 646-647Crossref PubMed Scopus (29) Google Scholar, 14Jamous F. Meyer N. Buus D. et al.Critical illness due to Covid-19: a description of the surge in a single center in Sioux Falls.S D Med. 2020; 73: 312-317PubMed Google Scholar In some of these cases, invasive or noninvasive mechanical ventilation was applied before the development of pneumothorax,6Liu K. Zeng Y. Xie P. et al.COVID-19 with cystic features on computed tomography: a case report.Medicine (Baltimore). 2020; 99e20175Crossref PubMed Scopus (84) Google Scholar,9Aiolfi A. Biraghi T. Montisci A. et al.Management of persistent pneumothorax with thoracoscopy and bleb resection in COVID-19 patients.Ann Thorac Surg. 2020; 110: e413-e415Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar,12Janssen M.L. van Manen M.J.G. Cretier S.E. Braunstahl G.J. Pneumothorax in patients with prior or current COVID-19 pneumonia.Respir Med Case Rep. 2020; 31: 101187PubMed Google Scholar, 13Volpi S. Ali J.M. Suleman A. Ahmed R.N. Pneumomediastinum in COVID-19 patients: a case series of a rare complication.Eur J Cardiothorac Surg. 2020; 58: 646-647Crossref PubMed Scopus (29) Google Scholar, 14Jamous F. Meyer N. Buus D. et al.Critical illness due to Covid-19: a description of the surge in a single center in Sioux Falls.S D Med. 2020; 73: 312-317PubMed Google Scholar whereas in other cases it appeared after several weeks of pulmonary involvement, with large inflammatory infiltration and cyst formation in the pulmonary parenchyma.6Liu K. Zeng Y. Xie P. et al.COVID-19 with cystic features on computed tomography: a case report.Medicine (Baltimore). 2020; 99e20175Crossref PubMed Scopus (84) Google Scholar,9Aiolfi A. Biraghi T. Montisci A. et al.Management of persistent pneumothorax with thoracoscopy and bleb resection in COVID-19 patients.Ann Thorac Surg. 2020; 110: e413-e415Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar,10Sun R. Liu H. Wang X. Mediastinal emphysema, giant bulla, and pneumothorax developed during the course of COVID-19 pneumonia.Korean J Radiol. 2020; 21: 541-544Crossref PubMed Scopus (206) Google Scholar Indeed, only a few case series have described the frequency of pneumothorax in COVID-19, being reported as present in 1% of 99 hospitalized patients,2Chen N. Zhou M. Dong X. et al.Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study.Lancet. 2020; 395: 507-513Abstract Full Text Full Text PDF PubMed Scopus (13646) Google Scholar in 3% of patients hospitalized with pneumonia,14Jamous F. Meyer N. Buus D. et al.Critical illness due to Covid-19: a description of the surge in a single center in Sioux Falls.S D Med. 2020; 73: 312-317PubMed Google Scholar in 6% of 202 mechanically ventilated patients,15Yao W. Wang T. Jiang B. et al.Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.Br J Anaesth. 2020; 125: e28-e37Abstract Full Text Full Text PDF PubMed Scopus (236) Google Scholar and in 1% of 91 deceased patients.16Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol. 2020;92(11):2511-2515.Google Scholar For most of these patients, noninvasive or invasive mechanical ventilation probably contributed to this relatively high incidence. In the present study, we aimed to investigate the frequency of SP in patients attended in the ED, before hospitalization and treatment with specific drugs for SARS-CoV-2 infection and before the initiation of ventilatory support. The specific objectives were as follows: (1) to determine the relative frequency of SP in patients with COVID-19 coming to the ED as well as estimate the annual standardized incidence; (2) to uncover the risk factors associated with the development of SP in patients with COVID-19; (3) to describe whether these patients have any distinctive clinical characteristic compared with SP observed in non-COVID-19 patients; and (4) to investigate the outcomes of patients with COVID-19 presenting with SP. The present study forms part of the Unusual Manifestations of COVID-19 (UMC-19) project, which was designed to investigate the potential relationship between COVID-19 and 10 different entities that could be influenced by SARS-CoV-2 infection itself: SP, acute pancreatitis, meningoencephalitis, Guillain-Barré syndrome, (myo)pericarditis, acute coronary syndrome, DVT, pulmonary embolism, ictus, and GI bleeding. The main objectives of the UMC-19 project were common for all of the entities and consisted in the description of the incidence, risk factors, clinical characteristics, and outcomes for each particular entity, using patients with COVID-19 who did not develop these entities as well as non-COVID-19 patients who presented these entities as comparators. Complete details of the UMC-19 project have been published elsewhere.17Miró O. González del Castillo J. Collaboration among Spanish emergency departments to promote research: on the creation of the SIESTA (Spanish Investigators in Emergency Situations Team) Network and the coordination of the UMC-19 (Unusual Manifestations of COVID-19) microproject.Emergencias. 2020; 32: 269-277PubMed Google Scholar In Spain, the first case of SARS-CoV-2 infection was detected on January 31, 2020 and, accordingly, the COVID-19 period for the inclusion of case subjects in the present UMC-19 study project was set from March 1 to April 30, 2020. For the recruitment of control subjects, the UMC-19 project selected patients from two different periods: one corresponding to the same dates as the case subjects (from March 1 to April 30, 2020) and one corresponding to the same period of the previous year (from March 1 to April 30, 2019). The investigators of the UMC-19 project initially contacted 152 Spanish EDs, which constitute roughly one-half of the 312 hospital EDs of the Spanish public health network. Of these, 81 considered participation and analyzed the protocol, and finally 61 (20% of Spanish EDs) consented to participate and duly sent all the data required (Fig 1). Altogether, these 61 hospitals provide health coverage to 14,537,000 citizens (31% of the population of 46.9 million of Spain) and make up a balanced representation of the Spanish territory (representing 12 of the 17 Spanish autonomous communities), type of hospital (community, reference, and high-technology university hospitals were included), and involvement in the pandemic (with EDs attending from 1% to 47% of the ED census during the COVID-19 outbreak period corresponding to patients with COVID-19).17Miró O. González del Castillo J. Collaboration among Spanish emergency departments to promote research: on the creation of the SIESTA (Spanish Investigators in Emergency Situations Team) Network and the coordination of the UMC-19 (Unusual Manifestations of COVID-19) microproject.Emergencias. 2020; 32: 269-277PubMed Google Scholar The investigation of SP in patients with COVID-19, one of the entities included in the UMC-19 project, was labeled as UMC-19 Study 7 (UMC-19-S7) and consisted of a retrospective, case-control, multicenter study that reviewed the medical reports of patients with COVID-19 attended and diagnosed with SP during ED assessment and treatment in Spanish EDs before hospitalization. As the UMC-19-S7 was conceived as an exploratory study, sample size was not predetermined. The case group was formed by patients with COVID-19, with the diagnosis of SP being made on the basis of chest radiography or thoracic CT imaging. All SPs were confirmed by radiologists and/or thoracic surgeons. Patients in whom pneumothorax developed as a consequence of trauma, manipulations, or other secondary causes were excluded. On the other hand, the diagnosis of COVID-19 was accepted on the basis of SARS-CoV-2 antigen detection in a nasopharyngeal swab by reverse transcriptase-polymerase chain reaction (RT-PCR), a clinically compatible clinical picture (including at least malaise, fever, and cough) or the presence of typical lung parenchymal infiltrates on chest radiography (bilateral interstitial lung infiltrates and ground-glass infiltrates) in patients with some clinical symptoms attributable to COVID-19. Diagnostic adjudication was done by the principal investigator of each center without external review. We defined two different control groups. One group was formed by patients with COVID-19 (without SP) attending the ED during the same COVID-19 outbreak period used for case inclusion (March 1 to April 30, 2020). As the number of COVID-19 patients with SP included in the UMC-19-S7 was expected to be very low, we planned to select 10 patients with COVID-19 for every case detected by each center, to maximize the statistical power as much as possible. Selection was performed by inclusion of the 10 patients with COVID-19 seen immediately before (five patients) and after (five patients) each case subject included by the center. This group, named control group A, was specifically designed to uncover the risk factors associated with SP development in patients with COVID-19. The second control group was made up of non-COVID-19 patients with a diagnosis of SP attending the ED during the same period as the case subjects (March 1 to April 30, 2020), which was defined in the same terms as for the case subjects. To avoid the possibility that some of these control case subjects could eventually have been inadvertently infected with SARS-CoV-2, or that some with mild symptoms could have remained at home during the COVID-19 outbreak due to fear of COVID-19 contagion, we also included patients with SP diagnosed in the ED from March 1 to April 30, 2019, just 1 year before the COVID-19 pandemic. On the basis of the same principle of maximizing the statistical power as much as possible, we planned to include and review all non-COVID-19 patients with SP identified in these two periods (the COVID-19 period in 2020 and the pre-COVID-19 period in 2019). This group, named control group B, was specifically designed to uncover the particular distinctive clinical characteristics of SP developed in COVID-19 patients with respect to SP developed in the general population. We collected 52 independent variables, which included two demographic data (age, sex), 12 comorbidities (COPD, asthma, active smoker, hypertension, dyslipidemia, diabetes mellitus, coronary artery disease, obesity [clinically estimated], cerebrovascular disease, chronic kidney disease [creatinine > 2 mg/dL], dementia, active cancer), 16 related to symptomatology (time elapsed from symptom onset to ED attendance, fever, rhinorrhea, cough, expectoration, dyspnea, chest pain, syncope, hemoptysis, abdominal pain, vomiting, diarrhea, confusion, headache, anosmia, dysgeusia), five vital signs at ED arrival (temperature, systolic BP, heart rate, respiratory rate, room air pulse oximetry reading), nine laboratory parameters (C-reactive protein, creatinine, aspartate aminotransferase, lactate dehydrogenase, procalcitonin, hemoglobin, leukocytes, lymphocytes, D-dimer), and eight radiologic findings on chest radiography (cardiomegaly, pleural effusion, interstitial lung infiltrates, and ground-glass opacities; and location, extension, and accompanying pneumomediastinum and subcutaneous emphysema in patients with pneumothorax). All these variables were collected by retrospective review of all patient medical reports obtained during ED and hospital stay. We defined four different outcomes for case subjects and control subjects, which consisted of (1) the need for hospitalization, (2) the need for admission to intensive care, (3) prolonged hospitalization (defined as a length of stay > 7 days, which is the median length of stay of hospitalized patients in Spain), and (4) in-hospital all-cause mortality. Outcomes were determined after retrospective review of all patient medical reports obtained during ED and hospital stay. Outcomes adjudication was done by the principal investigator of each center without external review. Discrete variables were expressed as absolute values and percentages, and continuous variables as mean and SD or median and interquartile range if not normally distributed. The relative frequency of SP was expressed per thousand (‰) COVID-19 or non-COVID-19 patients coming to the ED, and the annual standardized incidence was expressed per 100,000 COVID-19 or non-COVID-19 individuals. Both estimations were made with 95% CIs that were calculated using the exact method for binomial distributions. To estimate the COVID-19 and non-COVID-19 population in each ED catchment area, we used the seroprevalence of SARS-CoV-2 in the province where the ED was located. These detailed seroprevalences were determined in a wide Spanish study performed between April 27 and May 11, 2020, and have recently been reported.18Pollán M. Pérez-Gómez B. Pastor-Barriuso R. et al.Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study.Lancet. 2020; 396: 535-544Abstract Full Text Full Text PDF PubMed Scopus (1139) Google Scholar Differences between the case and the control groups were assessed by the χ2 test (or Fisher exact test if needed) for qualitative variables, and the Student t test (or the Mann-Whitney nonparametric test if nonnormally distributed) for quantitative variables. Correction for multiple comparisons was performed by the Bonferroni method. The magnitude of associations remaining statistically significant after this correction was expressed as unadjusted ORs with 95% CIs, which were calculated by logistic regression independently comparing all case subjects with all control A patients, and all case subjects with all control B patients. Continuous variables were dichotomized using clinically meaningful cutoffs or around the median of distribution. As the number of patients with SP we expected to identify was not large, we did not plan to go further in the investigation of the significant relationships of risk factors and clinical characteristics identified in the unadjusted analysis using adjusted models. On the other hand, outcomes analysis is presented as unadjusted and adjusted for age and sex and, in addition, we also added center to obtain further adjustment. Sensitivity analysis for the comparison between case subjects and control A patients, using only those with microbiologic confirmation of SARS-CoV-2 infection, was performed for the clinical characteristics found to be statistically significant in the main analysis and for the outcomes. In all comparisons, statistical significance was accepted if the P value was < .05 or if the 95% CI of the risk estimations excluded the value 1. All the analyses were performed with the SPSS (version 24) statistical software package (IBM). The UMC-19 project was approved by the Ethics Committee of the Hospital Clínic of Barcelona (Spain) (reference number HCB/2020/0534), which acted as the central ethics committee. Under the exceptional circumstances generated by the COVID-19 pandemic, the urgent need to obtain feasible data related to this new disease, and the noninterventional and retrospective nature of the project, the requirement that written patient consent be obtained to be included in the study was waived. All patients were codified by investigators of the participating centers before entering their data into the general database, thereby ensuring patient anonymity to investigators analyzing the database. The UMC-19-S7 was carried out in strict compliance with the principles of the Declaration of Helsinki. The authors designed the study, gathered and analyzed the data, vouched for the data and analysis, wrote the article, and decided to publish. A total of 71,904 patients with COVID-19 were seen in the 61 Spanish EDs participating in the UMC-19-S7 (Fig 1) during the 61-day study period. Forty of these patients presented SP (0.56‰; 95% CI, 0.40‰-0.76‰) and constituted the case group. Control group A was formed by 400 selected patients without SP (COVID-19 non-SP) during the same period. Confirmation of SARS-CoV-2 infection by RT-PCR was performed in 75.0% and 74.8% of patients, respectively. On the other hand, 1,358,134 non-COVID-19 patients were seen during the 122-day period (414,929 during the 61 days in the 2020 COVID-19 period, and 943,205 during the 61 days of the 2019 pre-COVID-19 period). Of these, 387 were diagnosed with SP (134 in the COVID-19 period and 253 in the pre-COVID-19 period). Accordingly, the overall relative frequency for the whole period was 0.28‰ (95% CI, 0.26‰-0.32‰), with relative frequencies during the COVID-19 and pre-COVID-19 periods of 0.32‰ (95% CI, 0.27‰-0.38‰) and 0.27‰ (95% CI, 0.24‰-0.30‰), respectively. These 387 patients constituted control group B. A pleural tube for pneumothorax drainage was placed in 29 of 40 patients of the case group (73%) and in 306 of the 387 patients in control B group (79.1%; P = .32). The relative frequency of SP in COVID-19 compared with non-COVID-19 patients coming to the ED resulted in an OR of 1.93 (95% CI, 1.41-2.71), with ORs of 1.72 (95% CI, 1.21-2.45) and 2.07 (95% CI, 1.49-2.90) when comparisons were made with non-COVID-19 patients diagnosed during the COVID-19 and pre-COVID-19 periods separately, respectively. On the other hand, the standardized incidences of SP were 34.2 per 100,000 COVID-19 individuals per year (95% CI, 30.0-38.9), and 8.2 per 100,000 non-COVID-19 individuals per year (95% CI, 7.7-8.7; with partial standard incidences of 5.8 [95% CI, 5.4-6.2] in the COVID-19 period and 10.4 [95% CI, 9.9-11.0] in the pre-COVID-19 period). Accordingly, the OR for the standardized incidence in COVID-19 patients compared with non-COVID-19 patients was 4.19 (95% CI, 3.64-4.81); with an OR with respect to the COVID-19 period of 5.89 (95% CI, 5.10-6.81) and an OR with respect to the pre-COVID-19 period of 3.28 (95% CI, 2.86-3.76).The analysis of relative frequencies and standardized incidences by Spanish geographical regions showed some variability, although most ORs remained statistically significant (Fig 2). The mean age of the COVID-19 patients with SP (case subjects) was 66 years, 73% were male, 20% had asthma, 10% had COPD, and 10% were active smokers. The most frequent symptomatology was dyspnea (88%), cough (53%), chest pain (40%), and fever (38%), and the median time from symptom onset to ED consultation was 5 days. The remaining clinical characteristics, as well as the vital signs at ED arrival and laboratory findings, are presented in Table 1. Cardiomegaly and pleural effusion were rarely seen in these patients (in 11% and 3% of radiographs, respectively), but interstitial lung infiltrates and ground-glass opacities were frequently observed (in about one-half of the patients). The location of SP was in the right lung in 81% of cases, with an extension ranging from minimal to massive, and was accompanied by pneumomediastinum and subcutaneous emphysema in 16% of cases (Table 1). In three case subjects and 15 patients in control group B, chest radiography was not performed in the ED, and SP diagnosis was made by thoracic CT imaging.Table 1Baseline Characteristics of COVID-19 Patients With Spontaneous Pneumothorax and Comparison With COVID-19 Patients Without Spontaneous Pneumothorax (Control Group A) and With Non-COVID-19 Patients With Spontaneous Pneumothorax (Control Group B)CharacteristicCase Subjects (COVID-19-SP)(n = 40)Comparison With Control Group AComparison With Control Group BControl Group A (COVID-19-Non-SP)(n = 400)P ValueaP values refer to comparison between case subjects and control group A.P Value (Corrected)bP values refer to comparison of statistically significant variables between case subjects and control group A after Bonferroni correction for multiple comparisons.Control Group B (Non-COVID-19-SP)(n = 387)P ValuecP values refer to comparison between case subjects and control group B.P Value (Corrected)dP values refer to comparison of statistically significant variables between case subjects and control group B after Bonferroni correction for multiple comparisons.Demographics Age, median (IQR), y66 (47-74)61 (46-77).93...36 (22-57)< .001< .001 Sex, male29 (72.5)205 (51.3).012> .05303 (78.3).43...Pulmonary comorbidities COPD4 (10.0)33 (8.3).76...58 (15.0).49... Asthma8 (20.0)27 (6.8).009> .0522 (5.7).004> .05 Active smoker4 (10.0)26 (6.5).34...146 (37.7)< .001.02Other comorbidities Hypertension15 (37.5)168 (42.0).62...48 (12.4)< .001.001 Diabetes mellitus7 (17.5)74 (18.5)1.00...23 (5.9).02> .05 Active cancer5 (12.5)38 (9.5).57...41 (10.6).79... Coronary artery disease4 (10.0)30 (7.5).54...8 (2.1).02> .05 Obesity (clinically estimated)3 (7.5)57 (14.3).33...8 (2.1).07... Chronic kidney disease1 (2.5)34 (8.5).35...14 (3.6)1.00... Cerebrovascular disease1 (2.5)29 (7.3).50...13 (3.4)1.00..." @default.
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• W3104014378 title "Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019" @default.
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