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 Table of Contents  
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 299-301

Intercostal chest tube drain-related bleeding in a severe COVID-19 pneumonia patient with pneumothorax and its management

1 Department of Anesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Anesthesiology and Critical Care, Military Hospital, Ambala, Haryana, India

Date of Submission08-Sep-2021
Date of Decision26-Oct-2021
Date of Acceptance30-Oct-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Kaminder Bir Kaur
Department of Anesthesiology and Critical Care, Military Hospital, Ambala - 133 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_205_21

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Pneumothorax and pneumomediastinum have both been noted to complicate cases of coronavirus disease-19 (COVID-19) requiring hospital admission; however, the incidence is very low with only few cases reported in the literature. Spontaneous pneumothorax was also reported as a complication of the severe acute respiratory syndrome (SARS) with an incidence of 1.7% in hospitalized patients during the SARS pandemic of 2004. COVID-19 is also associated with a hypercoagulable state leading to pulmonary microvasculature thrombosis and systemic thromboembolic manifestations. Therefore, it is standard practice to start low molecular weight heparin (LMWH) for all moderate and severe COVID-19 pneumonia patients. We report a case of spontaneous pneumothorax in a severe COVID-19 pneumonia patient after three weeks of admission, where placing an intercostal drain (ICD) led to persistent bleeding into the ICD. He was managed with an innovative technique of instillation of Adrenaline saline solution three times into the pleural cavity through the ICD tube. Following the instillation of Adrenaline saline solution, the bleeding from the ICD stopped, however, the patient succumbed to his illness.

Keywords: Adrenaline, case report, COVID-19, pneumothorax

How to cite this article:
Jahan N, Kaur KB, Chapperwal P, Tiwari P. Intercostal chest tube drain-related bleeding in a severe COVID-19 pneumonia patient with pneumothorax and its management. Arch Med Health Sci 2021;9:299-301

How to cite this URL:
Jahan N, Kaur KB, Chapperwal P, Tiwari P. Intercostal chest tube drain-related bleeding in a severe COVID-19 pneumonia patient with pneumothorax and its management. Arch Med Health Sci [serial online] 2021 [cited 2022 Aug 19];9:299-301. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/299/334007

  Introduction Top

Coronavirus disease 2019 (COVID-19) is a communicable disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first detected in the city of Wuhan, China, and was declared a pandemic by the World Health Organization in March 2020.[1],[2] Radiological imaging plays an important role in the diagnosis and follow-up of COVID-19 pneumonia.[3] Common computerized tomography (CT) findings in COVID-19 are of patchy ground-glass opacities with a peripheral or posterior distribution, mainly involving the lower lobes.[4] Pleural effusion, pericardial effusion, lymphadenopathy, cavitation, CT halo sign, and pneumothorax are some of the uncommon possible findings seen with disease progression.[5]

  Case Report Top

A 54-year-old male patient, presented with fever and increasing breathlessness of 3 days. At the time of presentation, his room air saturation (SpO2) was 73%, with a pulse rate of 110/min, respiratory rate of 34/min, and blood pressure of 126/86 mmHg. His reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2 was positive. The initial complete blood count showed normal hemoglobin and total leukocyte count with platelet count of 1, 48,000 (reference range; 1, 50,000 – 450,000). His prothrombin time was 13.5 s against the laboratory control of 13 s with activated partial thromboplastin time of 36.5 s against the laboratory control of 35 s. He was admitted to a temporary COVID hospital as a case of severe COVID-19 pneumonia. He was placed on non-rebreathing mask (NRBM) with oxygen @ 8L/min. Strict COVID awake repositioning/proning protocol (CARP) was followed. Patient was administered injection Remdesevir 200 mg intravenous (IV) on day 1 followed by 100 mg IV once a day for the next 4 days, injection Ceftriaxone 1 g IV twice a day, injection dexamethasone 6 mg IV once a day, and injection Low Molecular Weight Heparin (LMWH) 60 mg subcutaneous once a day.

After 2 days of admission, the oxygen requirement of the patient increased and the patient was placed on High Flow Nasal Cannula (HFBNO), @60 L/min with FiO2 of 1.0. The patient was stabilized with these flows and CARP. The patient improved gradually over the next 17 days and his oxygen requirements reduced. On day 18 he was placed on nasal prongs @2 lit/min.

At this time, the patient was shifted to step down intensive care unit and was ambulated. On day 21 of his admission, his RT-PCR became negative and he was planned for discharge from the hospital. On day 22, the patient developed sudden breathing difficulty at 0530 h in the morning. On examination, he had tachypnoea and tachycardia and his SpO2 was 70% with NRBM. Hence, he was placed on HFNC @60 L/min, however, this too did not improve his symptoms and the SpO2 remained low <80%. It was noticed that the left side of the chest was not moving. Clinically, it appeared to be a case of pneumothorax. Bedside lung ultrasound was done, which revealed the absence of pleural slide on the left side. Immediate decompression was done with needle thoracostomy in the triangle of safety on the left side. While the preparations for intercostal drain (ICD) insertion were on, the patient developed a sudden bradycardia which rapidly progressed to cardiac arrest. CPR was started as per standard ACLS protocol and the patient was immediately revived.

The patient was Intubated and placed on mechanical ventilation on SIMV mode. At this point, he started developing hypotension for which infusion of Noradrenaline was started and a size 30 F ICD was placed in the left 5th intercostal space in the triangle of safety. A gush of air bubbles was observed in the underwater seal drain. After about 30 min we observed a continuous trickle of fresh blood in the ICD [Figure 2]a, [Figure 2]b. We attributed it to the fact that the patient was on prophylactic dose LMWH. To control the bleeding we decided to try instillation of 1: 100,000 Adrenaline saline solution. The patient end of the ICD was clamped, the underwater drain bag tubing was disconnected from the ICD in a sterile manner, and 20 ml of Adrenaline saline solution was instilled into the ICD, the drain bag tubing was connected and the clamp on the ICD towards the patient was opened to allowed to drain into the pleural cavity. The clamp was reapplied for 10 min after the Adrenaline solution had drained into the pleural cavity. After 10 min, the patient end was declamped and the column movement was confirmed. This process was repeated thrice with an interval of 10 min in between. The bleeding decreased significantly after the first instillation and completely stopped after the third instillation of 20 ml Adrenaline saline [Figure 1]b.
Figure 1: This radiograph shows residual pneumothorax even after ICD placement as the patient had developed a Broncho-pleural fistula.

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Figure 2: (a) The blood-stained fluid in the underwater seal following the insertion of the intercostal drainage tube. (b) The clear fluid in the underwater seal container after instillation of adrenaline solution through the chest tube

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By the evening, this patient had developed a bronchopleural fistula and became more hypoxic and hemodynamically unstable [Figure 1]. With maximal ventilatory and inotropic support also, his clinical condition did not improve and he succumbed to his illness the following day. Informed written consent was taken from the next of kin for the publication of this manuscript.

  Discussion Top

A procoagulant state is a widely recognized issue in COVID-19. British Thoracic Society and Scottish Intercollegiate Guidelines Network currently suggest the use of prophylactic dose LMWH for patients who are managed in a ward and therapeutic dose LMWH for patients in critical care settings.[6] Retrospective studies of patients with COVID-19 suggested that pneumothorax might occur in 1% of those requiring hospital admissions, 2% of those requiring ICU admission, and 1% of patients dying from the infection.[7],[8],[9] Martinelli et al. in their meta-analysis in non-ventilated COVID-19 patients showed that pneumothorax is more common in males with lower survival in the over 70 yrs age group.[10] Explaining the relationship between pneumothorax and COVID-19 is challenging with multiple possible mechanisms underlying this relationship. Pneumatoceles or cysts in patients with COVID-19 are described in the literature, even in patients not requiring positive pressure ventilation. This means that barotrauma associated with positive pressure ventilation alone cannot account for the cyst formation, which may contribute to the likelihood of developing a secondary pneumothorax.[11]

Pneumothorax is an emergency requiring the placement of ICD into the pleural cavity. Derangement of coagulation profile and addition of anticoagulants increase the risk of procedure-related bleeding in these patients. However, insertion of an ICD is a lifesaving emergency procedure and has to be done irrespective of the coagulation profile. The risk of hemorrhagic complications after tube thoracostomy is 0.2%–1.4%.[12] Fresh frozen plasma can be used prophylactically in patients' with deranged international normalized ratio (INR); however randomized controlled trials have shown that there was no difference in the rate of bleeding complications in patients with mild coagulopathy following chest tube insertion who received prophylactic FFP and who did not.[13] To the best of our knowledge, there is no literature available on the hemorrhagic complications of chest tube placement in COVID-19 patients.

We performed ICD insertion immediately, but the patient had bleeding in the chest tube. Hence, we thought of trying instillation of 1:100,000 adrenaline saline, which effectively stopped the bleeding. The instillation may be repeated every 10-15 min till the bleeding stops. To the best of our knowledge, this is the first time when adrenaline solution has been used to stop the bleeding from the chest tube. It is important to remember that the procedure must be done with strict aseptic technique and the ICD must be clamped for 10 min after instillation of adrenaline saline. The instillation of Adrenaline saline in the pleural space might lead to tachycardia and hypertension if large quantities of thew solution are used. We did not see this in our case.

  Conclusion Top

The authors recommend the instillation of 20 ml of 1:100,000 Adrenaline saline into the pleural cavity through the ICD to stop procedure-related bleeding in COVID-19 patients on prophylactic or therapeutic dose LMWH therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.  Back to cited text no. 1
A Timeline of COVID-19 Developments in 2020; January 2021. Available from: https://www.ajmc.com/view/review-baseline-gut-m icrobiota-may-predict-immunotherapy-responses. [Last accessed on 2021 Jul 25].  Back to cited text no. 2
Zhao W, Zhong Z, Xie X, Yu Q, Liu J. Relation between chest ct findings and clinical conditions of coronavirus disease (COVID-19) pneumonia: A multicenter study. AJR Am J Roentgenol 2020;214:1072-7.  Back to cited text no. 3
Li X, Zeng W, Li X. CT imaging changes of corona virus disease 2019(COVID-19): A multi-center study in Southwest China. J Transl Med 2020;18:154.  Back to cited text no. 4
Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus disease 2019 (COVID-19): A systematic review of imaging findings in 919 patients. AJR Am J Roentgenol 2020;215:87-93.  Back to cited text no. 5
Gomez K, Laffan M, Bradbury C. Debate: Should the dose or duration of anticoagulants for the prevention of venous thrombosis be increased in patients with COVID-19 while we are awaiting the results of clinical trials? Br J Haematol 2021;192:459-66.  Back to cited text no. 6
Yang F, Shi S, Zhu J, Shi J, Dai K, Chen X. Analysis of 92 deceased patients with COVID-19. J Med Virol 2020;92:2511-5.  Back to cited text no. 7
Sihoe AD, Wong RH, Lee AT, Lau LS, Leung NY, Law KI, et al. Severe acute respiratory syndrome complicated by spontaneous pneumothorax. Chest 2004;125:2345-51.  Back to cited text no. 8
Marwah V, Choudhary R, Peter D, Bhati G. COVID-19 ARDS-related pneumomediastinum and pneumothorax. Med J Armed Forces India 2021;77:S515-6.  Back to cited text no. 9
Martinelli AW, Ingle T, Newman J, Nadeem I, Jackson K, Lane ND, et al. COVID-19 and pneumothorax: A multicentre retrospective case series. Eur Respir J 2020;56:2002697.  Back to cited text no. 10
Liu K, Zeng Y, Xie P, Ye X, Xu G, Liu J, et al. COVID-19 with cystic features on computed tomography: A case report. Medicine (Baltimore) 2020;99:e20175.  Back to cited text no. 11
Wolfe KS, Kress JP. Risk of procedural hemorrhage. Chest 2016;150:237-46.  Back to cited text no. 12
Müller MC, Arbous MS, Spoelstra-de Man AM, Vink R, Karakus A, Straat M, et al. Transfusion of fresh-frozen plasma in critically ill patients with a coagulopathy before invasive procedures: A randomized clinical trial (CME). Transfusion 2015;55:26-35.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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