Pneumothorax as a complication of lung volume recruitment

Abstract

Lung volume recruitment involves deep inflation techniques to achieve maximum insufflation capacity in patients with respiratory muscle weakness, in order to increase peak cough flow, thus helping to maintain airway patency and improve ventilation. One of these techniques is air stacking, in which a manual resuscitator is used in order to inflate the lungs. Although intrathoracic pressures can rise considerably, there have been no reports of respiratory complications due to air stacking. However, reaching maximum insufflation capacity is not recommended in patients with known structural abnormalities of the lungs or chronic obstructive airway disease. We report the case of a 72-year-old woman who had poliomyelitis as a child, developed torsion scoliosis and post-polio syndrome, and had periodic but infrequent asthma attacks. After performing air stacking for 3 years, the patient suddenly developed a pneumothorax, indicating that this technique should be used with caution or not at all in patients with a known pulmonary pathology

Pneumothorax in neuromuscular disease associated with lung volume recruitment and mechanical insufflation-exsufflation

“…When considering risk, the available literature suggests that pneumothorax associated with MI-E or LVR, while rare, is a known and potentially life-threatening complication. In 2013, Westermann et al published a case of pneumothorax following LVR, in which the patient required emergency intubation and spent 20 days in hospital following drainage and pleurodesis [6]. Suri et al reported two cases of pneumothorax associated with MI-E in patients with NMD, where one of the patients died due to cardiovascular collapse on re-expansion of the affected lung [7].…”

“…There is no published data identifying lung function thresholds or respiratory system compliance values for which the risk of pneumothorax secondary to MI-E or LVR increases. Given the rarity of this complication, it is unlikely that robust measures for risk of pneumothorax will be developed and instead clinicians will be required to make a judgement based on the patient's primary pathology, comorbidities [6], disease trajectory, and ability to perform the techniques safely [10]. Measuring the maximum inspiratory pressure reached during prescription of inflation therapy and ensuring the patient can remove the interface instantaneously may inform safety considerations.…”

Pneumothorax in neuromuscular disease associated with lung volume recruitment and mechanical insufflation‐exsufflation

“…When considering risk, the available literature suggests that pneumothorax associated with MI‐E or LVR, while rare, is a known and potentially life‐threatening complication. In 2013, Westermann et al published a case of pneumothorax following LVR, in which the patient required emergency intubation and spent 20 days in hospital following drainage and pleurodesis . Suri et al reported two cases of pneumothorax associated with MI‐E in patients with NMD, where one of the patients died due to cardiovascular collapse on re‐expansion of the affected lung .…”

“…There is no published data identifying lung function thresholds or respiratory system compliance values for which the risk of pneumothorax secondary to MI‐E or LVR increases. Given the rarity of this complication, it is unlikely that robust measures for risk of pneumothorax will be developed and instead clinicians will be required to make a judgement based on the patient's primary pathology, comorbidities , disease trajectory, and ability to perform the techniques safely . Measuring the maximum inspiratory pressure reached during prescription of inflation therapy and ensuring the patient can remove the interface instantaneously may inform safety considerations.…”

228th ENMC International Workshop:

“…In terms of safety, there are case reports of complications with externally applied lung insufflations [31,32] and a number of the conference participants reported personal clinical experience of isolated cases where the use of external assisted inspiratory support may have been associated with gastric distension or discomfort and pneumothorax. As the group noted, super maximal lung volumes have been clearly associated with barotrauma and volutrauma in the intensive care literature but the relationships in the spontaneously breathing, non-intubated patient are not well established.…”