Bilevel Nasal Positive Airway Pressure and Ballooning of the Stomach

doi:10.1378/chest.119.6.1965

Chest

Volume 119, Issue 6, June 2001, Pages 1965-1966

https://doi.org/10.1378/chest.119.6.1965 Get rights and content

We describe a case of severe gastric insufflation in a patient with amyotrophic lateral sclerosis who was receiving bilevel nasal positive airway pressure (BNPAP) ventilation (BiPAP; Respironics; Murrysville, PA). The injection of inspiratory flow into the esophagus, aerophagia, and air trapping below the gastroesophageal junction after a meal are probably the major causes. We suggest that BNPAP ventilation can be a cause of serious gastric insufflation in a patient who lies supine, especially after a meal, and attention should be paid to avoiding this complication by having the patient sit up for about half an hour after a meal.

Section snippets

Case Report

A 42-year-old woman with ALS complained of gastric distension after a lunch of soup and noodles. She had been receiving BNPAP treatment for a year because of a rapid decline in respiratory function. She was using a standard nasal mask. The system had been set in the “spontaneous/timed” mode, and the inspiratory and expiratory pressures had been set at 14 and 4 cm H₂O, respectively. Her cranial nerves were normal except for a slight weakness and atrophy of the tongue. She could speak, eat, and

Discussion

On the basis of the patient's comment, we determined that her gastric distension probably was a result of air injection by BNPAP ventilation. This opinion is supported by a report stating that aerophagia is observed in 13% of patients receiving BNPAP ventilation.² Gastric insufflation is reported in up to 50% of patients receiving noninvasive positive-pressure ventilation but is rarely intolerable, probably because the lower esophageal sphincter pressure is well above the inspiratory positive

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Cited by (39)

Effect of noninvasive respiratory support after extubation on postoperative pulmonary complications in obese patients: A systematic review and network meta-analysis
2023, Journal of Clinical Anesthesia
Obesity is associated with an increased risk of sleep-disordered breathing (SDB) and postoperative pulmonary complications (PPCs). Postoperative noninvasive respiratory support (NRS) has been recommended to obese patients despite the controversy about its benefit. The network meta-analysis (NMA) was used in this study to compare the effect of different methods of NRS on preventing PPCs in obese patients.
This study is a network meta-analysis.
Post-anesthesia care unit and inpatient ward.
20 randomized controlled trials involving 1184 obese patients were included in the final analysis.
One of the four NRS techniques, which include continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), high-flow nasal cannula (HFNC), or conventional oxygen therapy (COT), was performed after general anesthesia.
The primary outcome was the incidence of PPCs, e.g., atelectasis, pneumonia, hypoxemia, and respiratory failure. The secondary outcomes included the incidence of oxygen treatment failure and anastomotic leakage, oxygenation index, and length of hospital stay (LOS). RevMan 5.3 and STATA 16.0 were used to analyze the results and any potential bias.
Compared with COT, BiPAP and HFNC were both effective in reducing the occurrence of postoperative atelectasis. There were no significant differences in the occurrence of other PPCs including pneumonia, hypoxemia and respiratory failure between the four NRS techniques. CPAP and HFNC were superior to other techniques in improving oxygenation and shortening LOS respectively. No differences were found in oxygen treatment failure and anastomotic leakage between the patients with different NRS. HFNC ranked the first in five of the eight outcomes (hypoxemia, respiratory failure, treatment failure, anastomotic leakage, LOS) in this review by the surface under the cumulative ranking curve (SUCRA).
Among the four postoperative NRS techniques, HFNC seems to be the optimal choice for obese patients which shows certain advantages in reducing the risk of PPCs and shortening LOS.
Reflux events detected by multichannel bioimpedance smart feeding tube during high flow nasal cannula oxygen therapy and enteral feeding: First case report
2020, Journal of Critical Care
The use of high flow nasal cannula (HFNC) oxygen therapy is common in patients with respiratory distress to prevent intubation or ensure successful extubation. However, these critical patients also need medical nutritional support and practitioners are often reluctant to prescribe oral or enteral feeding, leading to a decrease in energy and protein intake. Vomiting and aspiration are the major concerns. A new technology detecting the presence and duration of gastro-esophageal reflux and preventing aspiration in real-time has been developed and our case shows how HFNC oxygen therapy exposes patients to significantly more reflux events as compared to mechanical ventilation. This is the first description of this technique observed in critical care.
High-flow nasal oxygen does not increase the volume of gastric secretions during spontaneous ventilation
2020, British Journal of Anaesthesia
Citation Excerpt :
It is thought to occur in up to 50% of all patients and to result in pulmonary aspiration in up to 5% of cases.11 Severe gastric insufflation can have serious consequences including hypoxaemia, pulmonary aspiration, acute respiratory distress syndrome and death.9,10 There are, however significant differences between noninvasive positive pressure ventilation systems and HFNO.
High-flow, heated, and humidified nasal oxygen therapy (HFNO) is frequently used in critical care and perioperative settings for a range of clinical applications. Much of the benefit of HFNO is attributed to generation of modest levels of positive airway pressure. Concern has been raised that this positive airway pressure may cause gastric insufflation, potentially increasing the risk of regurgitation and aspiration in an unprotected airway.
A prospective, interventional, assessor-blinded study was undertaken to evaluate the effects of HFNO on gastric content and gastric distension in healthy fasted adult volunteers assessed by ultrasonography. The primary outcome was the volume of gastric secretions. The secondary outcomes were the incidence of gastric air insufflation and the distribution of gastric antral grades.
Sixty subjects were enrolled. No subject was found to have air gastric distension either at baseline or after treatment with HFNO. All subjects had either a Grade 0 or Grade 1 antrum, with similar distribution of antral grades and similar volume of gastric secretions before and after treatment with HFNO.
There was no evidence that treatment with HFNO at flow rates of up to 70 L min⁻¹ for 30 min resulted in gastric distension or an increase in gastric secretions in healthy individuals breathing spontaneously. The generalisability of these findings to subjects under anaesthesia and patients with incompetence of the lower oesophageal sphincter or impaired gastric emptying requires further investigation.
NCT03134937.
An observational study on the practice of noninvasive ventilation at a tertiary level Australian intensive care unit
2020, Australian Critical Care
Citation Excerpt :
Presence of an NG tube during NIV therapy has some advantages. The NG tube reduces the risk of gastric distention and aspiration, allows for commencement of feeds, and provides a conduit for delivery of enteral medications.24,25 However, trauma during insertion, gastro-esophageal sphincter incompetence, nosocomial pneumonia, and risk of feed intolerance sometimes outweigh the benefits.26–29
Failure of Non-Invasive Ventilation (NIV) is associated with increased morbidity and mortality among critically ill patients. Although there is evidence of association between disease related factors and NIV failure, it is unclear whether factors related to NIV application contribute to NIV failure.
To evaluate NIV failure rate and factors associated with NIV failure.
Prospective, observational, pilot study conducted in a 23-bed, tertiary care Intensive Care Unit (ICU). NIV failure was defined as application of NIV resulting in intubation or death in ICU.
Amongst 238 patients admitted with respiratory failure, NIV was administered to 60 patients (34 males, 26 females) for a total of 70 application episodes. The etiology of respiratory failure included acute pulmonary edema (28.6%), acute lung injury (22.9%) and pneumonia (15.7%). The mean (SD) age was 62 (17.6) years, BMI 32.0 (8.5) kg/m² and median APACHE-II score 17.5 (14.0–23.8). NIV failure occurred in 22 out of 70 applications (31.4% [95%CI 20.0–43.0]). NIV failure assessed by simple logistic regression analysis, was associated with admission diagnosis (OR 6.0, 95%CI: 1.3–28.7, p = 0.03), use of bi-level NIV-PS (OR 5.00, 95%CI: 1.04–24.1, p = 0.04), presence of nasogastric tube (OR 6.20, 95%CI: 1.9–19.8, p < 0.01) and with short NIV breaks in the 2nd 24-hours (OR 0.96, 95%CI: 0.91–0.99, p = 0.04).
NIV failure was observed in 31.4%. Factors associated with NIV failure were etiology of respiratory illness, type of NIV support and short NIV breaks, presumably reflecting illness severity or progress of disease. The presence of a nasogastric tube during application of NIV may adversely impact NIV application.
Noninvasive positive pressure ventilation in the immediate post–bariatric surgery care of patients with obstructive sleep apnea: a systematic review
2017, Surgery for Obesity and Related Diseases
Citation Excerpt :
Caution has been advised with the use of NIPPV after bariatric surgery due to a few case reports of gastric insufflation that occurred with the use of bilevel positive airway pressure (BiPAP) [30–32]. Vasquez et al. reported 2 patients using BiPAP after open LRYGB who developed bowel distention and subsequent anastomotic leaks [32]. However, it remains uncertain whether the gastric distention in these patients was caused by the BiPAP or possibly a postoperative paralytic ileus.
Obstructive sleep apnea is common in morbidly obese patients, and noninvasive positive pressure ventilation (NIPPV) is the standard treatment. Postoperatively, NIPPV is highly effective in preventing hypoxia and apneic episodes; however, the concern of gastric distention leading to increased risk of an anastomotic dehiscence limits universal acceptance.
To perform a systematic review of the literature to determine if the use of NIPPV during immediate post–bariatric surgery care is safe.
Between January 1, 2000 and January 1, 2015 a comprehensive literature search for English-language articles was performed. Search terms were related to NIPPV use and bariatric surgery. Three reviewers independently reviewed the full-text version of the articles for relevance. Due to lack of randomized controlled trials and common incidence of zero for leak rate, a meta-analysis was not conducted.
A total of 824 studies were identified for screening using our search criteria, and 811 were rejected based on exclusion criteria. Thirteen studies with 5465 patients were identified for abstract review. All articles were either favorable or equivocal on the use of NIPPV in this patient population. Comparative studies did not identify an increased rate of anastomotic dehiscence in the patients who did receive NIPPV. The use of NIPPV was associated with a decreased risk of respiratory complications but not of reintubation or unplanned intensive care unit admission.
This systematic review of the available literature does not provide evidence of a signal that there is an increased anastomotic dehiscence risk when NIPPV is administered during immediate post–bariatric surgery care.
Unusual complication of noninvasive ventilation: The œsogastric pneumatosis associated with a subcutaneous emphysema
2014, Revue de Pneumologie Clinique
La ventilation non invasive (VNI) est une technique d’assistance ventilatoire permettant d’éviter l’intubation endotrachéale et ses complications potentielles, néanmoins elle comporte quelques complications qui sont généralement sans gravité à type d’érythème et/ou d’ulcérations cutanées, sécheresse buccale et nasale, irritation conjonctivale et rarement des lésions de barotraumatisme, de volotraumatisme ou d’insufflation gastrique avec nausées et vomissements. Nous rapportons le cas d’un patient qui a présenté une complication inhabituelle de la VNI : la pneumatose sous-muqueuse œsogastrique associée à un emphysème sous-cutané survenant à j2 d’une hépatectomie réglée compliquée d’un syndrome d’inhalation pulmonaire postopératoire.
The non-invasive ventilation (NIV) is a technique of ventilator support to avoid endotracheal intubation and its potential complications. However, it has some complications that are usually harmless to type of erythema and/or cutaneous ulcerations, mouth or nose dryness, conjunctival irritation and rarely lesions of barotrauma, volotrauma or gastric insufflation with nausea and vomiting. We report the case of a patient who had an unusual complication of NIV: sub mucosa gastro-esophageal pneumatosis associated with subcutaneous emphysema occurring on the second day after one hepatectomy which was settled but complicated with a postoperative pulmonary aspiration syndrome.

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Chest

Selected ReportsBilevel Nasal Positive Airway Pressure and Ballooning of the Stomach

Section snippets

Case Report

Discussion

Chest

Complication of noninvasive positive pressure ventilation

Respir Care

Selected Reports
Bilevel Nasal Positive Airway Pressure and Ballooning of the Stomach