Hemopneumothorax in a COPD Patient Treated with Noninvasive Positive Pressure Ventilation: The Risk of Attendant Anticoagulation

Abstract

Noninvasive positive pressure ventilation (NIPPV) modalities have been proven to be effective in the setting of exacerbations of chronic obstructive pulmonary disease (COPD). Reported complications include pneumothorax, increased work of breathing, gastric distension and air embolism. This case demonstrates that patients with severe COPD on anticoagulant therapy are potentially at risk for the serious complication of combined lung barotrauma and hemorrhage while on acute NIPPV therapy. This is the first reported case of hemopneumothorax complicating NIPPV therapy. Il est démontré que les modalités de ventilation en surpression non effractive (VSNE) sont efficaces pour calmer les exacerbations de la maladie pulmonaire obstructive chronique (MPOC). Les complications déclarées incluent un pneumothorax, un accroissement du travail ventilatoire, une distension gastrique et un aéroembolisme. Le présent cas démontre que les patients atteints de MPOC grave sous anticoagulothérapie sont potentiellement vulnérables à la grave complication de barotraumatisme pulmonaire combiné à une hémorragie pendant un traitement aigu de VSNE. C'est le premier cas déclaré d'hémopneumothorax compliquant un traitement de VSNE.T he use of noninvasive positive pressure ventilation (NIPPV) in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) is common, and often either prevents or serves as a bridge to intubation and ventilation. The efficacy has been supported by clinical trials in the acute setting (1), but it is poorly tolerated in the chronic setting (2). Adverse effects directly related to NIPPV therapy are rare, although patients will commonly fail to respond, ultimately requiring intubation and mechanical ventilation. No patient characteristics have been identified to consistently predict who will respond successfully to NIPPV therapy (2), although nonresponders have been identified as those with more severe disease or those with factors contributing to increased mouth leaks (3).The known adverse effects of NIPPV are rare but include increased work of breathing (4), barotrauma (5), ulcerations of the face from ill-fitting masks (6), limited access to airway secretions (6), gastric distension (6), aspiration (3), conjunctivitis (3) and air embolism (5). Hemothorax is an unreported complication of this therapy. We present the case of an 81-year-old man with severe bullous emphysema who developed a hemothorax while receiving NIPPV, likely facilitated by anticoagulation for his concomitant non-Q wave myocardial infarction. CASE PRESENTATIONAn 81-year-old male ex-smoker had a past medical history of COPD on home oxygen therapy (3 L/min via nasal prongs) and previous pneumonia complicated by a right-sided lung abscess three months before presentation, which was successfully treated without consequences. He had an episode of angina in the 1960s, but had had no further cardiac symptoms since that time. He had documented bullous emphysema and had been admitted to hospital several times in the past for exacerbatio...

Occurrence of pneumothorax during noninvasive positive pressure ventilation through a helmet

“…The helmet is reported to have the fewest complications among different interfaces for NPPV [5,11] and, therefore, is regarded as a safe technique to treat ARF [2,3,5]. Occurrence of pneumothorax has been reported during mask NPPV [6] in patients with neuromuscular diseases or cystic fibrosis [7][8][9] but not during helmet NPPV.…”

“…Although the face mask seems the most appropriate interface for NPPV in critically ill ARF patients [4], the nose mask is also used [1]. However, both NPPV masks are frequently associated with patient dissatisfaction [4,5] and serious medical complications [6][7][8][9][10].…”

Benefícios e complicações da ventilação mecânica não-invasiva na exacerbação aguda da doença pulmonar obstrutiva crônica

“…Problems such as aerophagia, hypecapnia, abdominal distension, vomit, bronchoaspiration, morning headaches, face compression injuries; gas embolism and lack of adjustment of patients are inherent to the method and may restrict use 1,29-35 . Raghavan et al 35 showed that patients with severe CPOD treated with anticoagulants are at higher potential risk of pulmonary barotraumas and hemorrhage during treatment with NIMV. The authors reported a clinical case of a patient who developed hemopneumothorax as a NIMV complication.…”

A more realistic relationship between covid 19 and hemopneumothorax

“…Chest radiography was consistent with hydropneumothorax. Chest drainage yielded frank blood, thereby validating a diagnosis of hemopneumothorax [ 5 ].…”

“…In view of these observations [ 4 , 5 ], the occurrence of covid 19-related pulmonary embolism could be a risk factor for hemopneumothorax.…”