- Email: [email protected]
Cautious Use of NIPPV in Patients With Large Hiatal Hernias
Miscellaneous SESSION TITLE: Miscellaneous SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM
Cautious Use of NIPPV in Patients With Large Hiatal Hernias Theo Trandafirescu Yaoyun Shen* and Zehra Tekin Icahn School of Medicine at Mount Sinai, New York, NY INTRODUCTION: Patients with COPD and hiatal hernia are often placed on noninvasive positive pressure ventilation (NIPPV) due to hypercapnia and hypoxia.We present a case of large hiatal hernia induced lung collapse with NIPPV therapy. CASE PRESENTATION: An 87 YOM with COPD and hiatal hernia presented with progressive SOB,cough and left sided pleuritic pain for 4 days. PE revealed respiratory distress, diffuse wheezing and accessory muscles use. Initial chest xray revealed unchanged chronic left hemidiaphragm elevation Initial ABG shows hypercapnia and hypoxemia.Patient was placed on BiPAP (10/5/60%) for COPD exacerbation and was started on nebulizers, antibiotics and steroids.On hospital day 2, a repeat portable CXR (image 1) was done, which showed worsening left hemidiaphragm elevation and complete opacification of the left lung. BiPAP was stopped, a nasogastric tube (NGT) and rectal tube were placed for decompression, and the patient was kept NPO.His respiratory status did not improve . Subsequent CT chest (image 2) showed a large left diaphragmatic hernia containing most of the stomach, distal transverse colon and proximal descending colon with complete atelectasis of the left lung. The patient eventually underwent diaphragmatic eventration repair.
MISCELLANEOUS
DISCUSSION: Complete lung collapse is seldom seen as a complication of NIPPV.In this case, we postulate that the NIPPV introduced in the gastrointestinal (GI) system lead to worsened and enlarging hiatal hernia, which eventually caused passive atelectasis of the left lung. Ventilation volume enters the respiratory system and the GI system depending on the respiratory system resistance and compliance and the esophageal sphincter pressure. 1 Patients with hiatal hernias have lower esophageal sphincter incompetence. 2 A similar complication of aerophagia was proposed in patients with previous esophagectomy. 3 Furthermore, gastric insufflation can lead to transient upper esophageal sphincter relaxation. 1 Loss of upper esophageal sphincter tone can lead to complications such as aspiration of gastric contents and pneumonia. A NGT placed on suction may be able to reduce esophageal-gastric insufflation and aspiration of gastric contents during NIPPV therapy in patients with large hiatal hernias. CONCLUSIONS: NIPPV should be used cautiously in patients with large diaphragmatic hernias due to possible complication of aerophagia leading to enlarging hernias causing atelectasis. NGT on suction should be used in conjunction of NIPPV therapy in patients with large hiatal hernias to prevent gastric insufflation and aspiration. Reference #1: Carron M, Freo U, BaHammam AS. Complications of non-invasive ventilation techniques:comprehensive qualitative review of randomized trials. Br J Anaesth. 2013 Reference #2: Pettersson GB, Bombeck CT, Nyhus LM. Influence of hiatal hernia on lower esophageal sphincter function. Annals of Surgery 1981 Reference #3: Raman V, MacGlaflin CE, Erkmen CP. NIPPV following esophagectomy: safety demonstrated in a pig model.Chest 2015 DISCLOSURE: The following authors have nothing to disclose: Theo Trandafirescu, Yaoyun Shen, Zehra Tekin No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.770
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
740A
[
152#4S CHEST OCTOBER 2017
]
Cautious Use of NIPPV in Patients With Large Hiatal Hernias Theo Trandafirescu Yaoyun Shen* and Zehra Tekin Icahn School of Medicine at Mount Sinai, New York, NY INTRODUCTION: Patients with COPD and hiatal hernia are often placed on noninvasive positive pressure ventilation (NIPPV) due to hypercapnia and hypoxia.We present a case of large hiatal hernia induced lung collapse with NIPPV therapy. CASE PRESENTATION: An 87 YOM with COPD and hiatal hernia presented with progressive SOB,cough and left sided pleuritic pain for 4 days. PE revealed respiratory distress, diffuse wheezing and accessory muscles use. Initial chest xray revealed unchanged chronic left hemidiaphragm elevation Initial ABG shows hypercapnia and hypoxemia.Patient was placed on BiPAP (10/5/60%) for COPD exacerbation and was started on nebulizers, antibiotics and steroids.On hospital day 2, a repeat portable CXR (image 1) was done, which showed worsening left hemidiaphragm elevation and complete opacification of the left lung. BiPAP was stopped, a nasogastric tube (NGT) and rectal tube were placed for decompression, and the patient was kept NPO.His respiratory status did not improve . Subsequent CT chest (image 2) showed a large left diaphragmatic hernia containing most of the stomach, distal transverse colon and proximal descending colon with complete atelectasis of the left lung. The patient eventually underwent diaphragmatic eventration repair.
MISCELLANEOUS
DISCUSSION: Complete lung collapse is seldom seen as a complication of NIPPV.In this case, we postulate that the NIPPV introduced in the gastrointestinal (GI) system lead to worsened and enlarging hiatal hernia, which eventually caused passive atelectasis of the left lung. Ventilation volume enters the respiratory system and the GI system depending on the respiratory system resistance and compliance and the esophageal sphincter pressure. 1 Patients with hiatal hernias have lower esophageal sphincter incompetence. 2 A similar complication of aerophagia was proposed in patients with previous esophagectomy. 3 Furthermore, gastric insufflation can lead to transient upper esophageal sphincter relaxation. 1 Loss of upper esophageal sphincter tone can lead to complications such as aspiration of gastric contents and pneumonia. A NGT placed on suction may be able to reduce esophageal-gastric insufflation and aspiration of gastric contents during NIPPV therapy in patients with large hiatal hernias. CONCLUSIONS: NIPPV should be used cautiously in patients with large diaphragmatic hernias due to possible complication of aerophagia leading to enlarging hernias causing atelectasis. NGT on suction should be used in conjunction of NIPPV therapy in patients with large hiatal hernias to prevent gastric insufflation and aspiration. Reference #1: Carron M, Freo U, BaHammam AS. Complications of non-invasive ventilation techniques:comprehensive qualitative review of randomized trials. Br J Anaesth. 2013 Reference #2: Pettersson GB, Bombeck CT, Nyhus LM. Influence of hiatal hernia on lower esophageal sphincter function. Annals of Surgery 1981 Reference #3: Raman V, MacGlaflin CE, Erkmen CP. NIPPV following esophagectomy: safety demonstrated in a pig model.Chest 2015 DISCLOSURE: The following authors have nothing to disclose: Theo Trandafirescu, Yaoyun Shen, Zehra Tekin No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.770
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
740A
[
152#4S CHEST OCTOBER 2017
]