Spontaneous pneumothorax and pneumomediastinum in COVID-19: Role and timing of surgical intervention – A systematic review

INTRODUCTION

The global COVID-19 pandemic, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to unprecedented challenges in the management of respiratory complications. While the primary manifestations of COVID-19 involve viral pneumonia and acute respiratory distress syndrome (ARDS), increasing clinical evidence has highlighted the occurrence of spontaneous pneumothorax (SP) and pneumomediastinum (PM) as noteworthy complications in these patients. These complications, although previously recognized in other viral pneumonias and ARDS, appear with distinctive incidence and clinical behavior in the context of COVID-19.^[1,2] SP refers to the presence of air within the pleural space without preceding trauma or iatrogenic injury, while PM involves the presence of free air within the mediastinal structures. Both conditions can significantly compromise respiratory function and are associated with increased morbidity, particularly in patients with severe lung involvement.^[3] The pathophysiology in COVID-19-related SP and PM is complex, involving alveolar damage secondary to viral cytopathic effects, diffuse alveolar inflammation, and the mechanical stresses of ventilation strategies, including both invasive and non-invasive modalities.^[4] Early in the pandemic, isolated case reports suggested that SP and PM could arise spontaneously, even in patients who were not mechanically ventilated, implying intrinsic viral-mediated lung injury as a contributing factor.^[5] Subsequent cohort and observational studies have shed light on the epidemiology, clinical features, and outcomes of these complications. However, management strategies remain variable, ranging from conservative oxygen therapy to invasive chest drainage and surgical intervention. While conservative and chest tube drainage approaches have been standard for uncomplicated cases, surgical intervention, mainly through video-assisted thoracoscopic surgery (VATS), is increasingly considered for patients with persistent air leaks, recurrent pneumothorax, or complicated clinical courses.^[6] The optimal timing and criteria for surgery in this unique patient population have not yet been standardized. This systematic review synthesizes current evidence from observational studies to elucidate the incidence, clinical characteristics, and outcomes of SP and PM in COVID-19, with a specific focus on the role and timing of surgical intervention. Our goal is to provide clinicians and surgeons with a comprehensive understanding to guide management decisions and improve patient outcomes.

METHODS

Search strategy

We systematically searched PubMed, Embase, and Scopus from January 2020 to April 2025 [Figure 1] using the following terms: (“COVID-19” OR “SARS-CoV-2”) AND (“spontaneous pneumothorax” OR “pneumomediastinum”) AND (“surgery” OR “surgical intervention” OR “thoracic surgery” OR “VATS”).

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Figure 1:

PRISMA chart. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

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RESULTS

Study selection and characteristics: From an initial pool of 164 articles, 12 observational studies met the inclusion criteria.^[7-18] These comprised 8 retrospective cohorts and 4 prospective studies, including 368 patients with COVID-19-associated SP and/or PM [Table 1].

DISCUSSION

This systematic review synthesizes current evidence on SP and PM as significant complications observed in patients with COVID-19, providing critical insights into their pathophysiology, clinical presentation, management, and particularly the role and timing of surgical intervention. The pathogenesis of these air leak syndromes in COVID-19 is complex and multifactorial. The SARS-CoV-2 virus induces diffuse alveolar damage through its cytopathic effects and the resultant intense inflammatory response, which compromises the alveolar-capillary barrier. This disruption predisposes to alveolar rupture and escape of air into the pleural space (causing SP) or into the mediastinum (causing PM). In addition, mechanical factors such as increased intrathoracic pressure due to vigorous coughing, ventilatory support with high positive pressure, or altered lung compliance contribute to the risk of air leaks.^[11] The presence of SP and PM in non-intubated patients strongly suggests that barotrauma alone cannot explain these complications; intrinsic viral-mediated lung injury and the Macklin effect – where alveolar rupture leads to air dissecting along bronchovascular sheaths into the mediastinum – play important roles.^[12] This multifactorial etiology highlights the unique pathophysiological landscape of COVID-19-related pulmonary complications. Clinically, SP and PM in COVID-19 patients often present with acute symptoms such as sudden onset chest pain, shortness of breath, and subcutaneous emphysema.^[13] These symptoms may herald rapid clinical deterioration, especially in patients with preexisting lung involvement or ARDS, where the respiratory reserve is already compromised. Early and accurate diagnosis is critical, and imaging modalities such as chest X-ray and computed tomography (CT) scans are invaluable tools not only for confirming the presence of air leaks but also for evaluating their extent and identifying any associated pulmonary abnormalities like consolidations or fibrosis. Management strategies must be individualized based on the size of the pneumothorax or PM, symptom severity, and the patient’s overall clinical status. The majority of patients with small or asymptomatic pneumothoraces or isolated PM respond well to conservative treatment, which typically includes supplemental oxygen therapy and careful clinical and radiologic monitoring. This approach aims to facilitate reabsorption of air and prevent unnecessary invasive procedures.^[17] In cases where the pneumothorax is large, symptomatic, or causing significant respiratory compromise, chest tube drainage is the next step and has demonstrated efficacy in resolving air leaks in many patients.^[18,19] However, a subset of patients experiences persistent air leaks lasting beyond 5–7 days, recurrent pneumothorax, or failure of conservative and drainage measures, which necessitates surgical intervention. VATS has emerged as the preferred surgical technique in this context due to its minimally invasive nature, which offers several advantages over traditional thoracotomy. [20] VATS allows for direct visualization and treatment of the air leak source through procedures such as bullectomy or bleb resection combined with pleurodesis, which reduces the risk of recurrence.^[21] The minimally invasive approach results in decreased post-operative pain, shorter hospital stays, faster recovery, and lower complication rates, all of which are particularly important in patients whose respiratory function is already compromised by COVID-19-related lung disease [Table 4].^[22]

Timing of surgical intervention is a critical determinant of patient outcomes. Evidence from the reviewed studies indicates that early surgery – performed within 7 days of pneumothorax diagnosis – is associated with shorter hospital length of stay, reduced pneumothorax recurrence rates, and improved respiratory function and survival. Early intervention likely prevents the progression of complications and mitigates the physiological burden of persistent air leaks or recurrent pneumothorax.^[23,24] Conversely, delayed surgical management or prolonged conservative treatment in patients with complicated air leaks can result in sustained morbidity, prolonged mechanical ventilation, increased intensive care unit utilization, and higher healthcare costs. Despite these encouraging findings, the current evidence base has notable limitations. Most data derive from retrospective observational studies with inherent selection bias, heterogeneous patient populations, variations in ventilatory and surgical management protocols, and inconsistent reporting of outcomes. The absence of prospective randomized controlled trials limits definitive conclusions regarding optimal surgical timing, precise indications for surgery, and long-term functional outcomes.^[25] Moreover, surgical decision-making in COVID-19 patients is complicated by concerns about perioperative risks related to active infection, coagulopathy, and overall patient fragility. Moving forward, there is a pressing need for well-designed prospective studies and multicenter registries that systematically evaluate the role of surgical intervention in COVID-19-associated SP and PM.^[26] Such studies should aim to identify clear patient selection criteria, optimal timing for surgery, standardized surgical techniques, and comprehensive outcome measures, including long-term respiratory function and quality of life. Furthermore, an investigation into adjunctive therapies that could reduce the incidence or severity of these air leak complications would be valuable.

CONCLUSION

SP and PM are increasingly recognized as serious complications in patients with COVID-19, affecting both ventilated and non-ventilated populations. While conservative management remains appropriate for many, surgical intervention plays an indispensable role in managing complicated or persistent cases. Early minimally invasive surgical management, particularly through VATS, offers improved clinical outcomes and reduced recurrence rates. Careful patient selection and timing of intervention are paramount. As the pandemic evolves, robust prospective studies are essential to optimize therapeutic strategies and enhance patient prognosis in this complex clinical scenario.