Lung Infections Causing Pneumonia and Possible Tension Pneumothorax
COVID-19 pneumonia is the most clinically significant lung infection that can cause both pneumonia and subsequent tension pneumothorax, even in patients without prior lung disease and after recovery from the acute infection phase.
COVID-19 as the Primary Infectious Cause
COVID-19 pneumonia has emerged as a notable cause of secondary tension pneumothorax, with several critical features:
- Tension pneumothorax can develop in COVID-19 patients with no prior history of lung disease, representing a severe life-threatening complication 1
- The complication can occur even after release from isolation and clinical improvement, not just during severe illness 2, 3
- Bilateral tension pneumothorax has been documented, occurring up to 18 days after initial COVID-19 infection 4
- The mechanism involves diffuse lung injury from cytokine storm during infection, leading to formation of subpleural thin-walled cystic lesions (bullae) that can spontaneously rupture 2, 4
Clinical Presentation and Recognition
The presentation is typically dramatic and requires immediate recognition:
- Sudden onset of chest pain, dyspnea, and severe respiratory distress after coughing or spontaneously 1, 3
- Physical findings include oxygen saturation as low as 75% on room air, tachycardia, and diminished breath sounds 4
- Imaging reveals large pneumothorax with mediastinal shift, confirming tension physiology 2, 1
Critical Management Principles
Immediate needle decompression followed by chest tube placement is life-saving and must be performed emergently 5:
- Insert a cannula of at least 4.5 cm length into the second intercostal space in the mid-clavicular line 5
- Leave the cannula in place until a functioning chest tube is positioned 5
- Never clamp a bubbling chest drain, as this can lead to fatal tension pneumothorax 6
Important Clinical Pitfalls
Several critical warnings apply to this complication:
- Tension pneumothorax should be considered in any COVID-19 patient presenting with acute dyspnea and chest pain, even weeks after recovery 2, 4, 7
- The complication occurs not only in severe cases but also in patients with mild symptoms 4
- Bilateral pneumothorax must be assessed on initial examination to minimize mortality 4
- CT imaging may show resolution of cystic lesions within one month after treatment, with most patients recovering without long-term sequelae 2, 7
Other Infectious Considerations
While the evidence focuses on COVID-19, other bacterial pneumonias can theoretically lead to pneumothorax:
- Necrotizing pneumonias from organisms like Staphylococcus aureus, Streptococcus pneumoniae, and Klebsiella pneumoniae can cause lung destruction and air leaks 8, 9
- However, tension pneumothorax from these infections is rare and typically occurs in the context of severe necrotizing disease or empyema with bronchopleural fistula 6
Mechanical Ventilation Context
Patients on positive pressure ventilation who develop any pneumothorax should always receive tube thoracostomy, as positive pressure maintains the air leak and increases tension risk 5: