Respiratory Failure From Enlarging Diaphragmatic Hernia: A Rare Complication of Noninvasive Positive Pressure Ventilation

Abstract

SESSION TITLE: Obstructive Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Non-invasive positive pressure ventilation (NIPV) is useful for management of hypercapnic respiratory failure. Use of NIPV can have devastating complications.We report a rare case of diaphragmatic herniation that worsened due to gastric insufflation. CASE PRESENTATION: An 87-year-old man with history of COPD and left-sided diaphragmatic hernia presented with cough, worsening shortness of breath and wheezing. Vitals were significant for heart rate of 98 bpm, BP 140/90 mmHg, respiratory rate 28/min, and oxygen saturation 78% on room air. Physical examination demonstrated diffuse wheezing in the both lungs and tympanic percussion in the left hemi-thorax. The initial chest X-ray showed left hemi-diaphragm elevation (Figure 1). Patient was placed on bilevel NIPV (10/5 cm H2O and FIO2:60%) for hypercapnia due to COPD exacerbation. Patient’s respiratory distress worsened while on bilevel NIPV. Repeat CXR showed bowel loops compressing the whole left lung (Figure 2). NIPV was discontinued and patient was made NPO. CT thorax showed a large left diaphragmatic hernia containing most of the stomach, distal transverse colon, and proximal descending colon within the hernia. After discontinuing NIPV, patient’s respiratory status improved with O2 saturation of 95% on 2 L/min NC. Patient underwent surgical repair for bowel strangulation. Post-operative imaging confirmed re-expansion of the left lung with minimal basilar atelectasis and normal vasculature. Patient’s symptoms significantly improved after surgery. DISCUSSION: NIPV reduces the need for intubation, mortality, complications, and length of stay in COPD exacerbation. Some of the NIPV complications are mask intolerance, nasal bridge ulceration, inadequate gas exchange, sinus pain, aspiration and mucus plugging. Pneumothorax and pneumocephalus have been reported as the most serious complications of NIPV. Gastric insufflation is usually a minor adverse effect; however, our patient had significant worsening of diaphragmatic herniation and dyspnea due to to gastric insufflation with NIPV. CONCLUSIONS: There is no ideal target pressure when choosing NIPV settings. There should be a balance between inspiratory pressure supporting gas exchange and patient’s tolerance and comfort. When choosing NIPV physicians should watch for pre-existing diaphragmatic hernia and be aware that applying NIPV could potentially worsen herniation and gas exchange. Reference #1: Gay PC1.Complications of noninvasive ventilation in acute care.Respir Care. 2009 Feb;54(2):246-57. DISCLOSURE: The following authors have nothing to disclose: Mahsan Farokhi, Viren Kaul, Assad Oskuei, Michael Megally, Daniel Nicastri, Martin Warshawsky No Product/Research Disclosure Information