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A6682 - Spontaneous Pneumothorax Caused by Excessive Positive Airway Pressure Therapy for Obstructive Sleep Apnea
Author Block: J. T. Mao1, A. Bernabei2, N. Cutrufello3, J. D. Kern4; 1Div. of Pulmonary, Critical Care and Sleep, New Mexico VA health Care System/Univ of New Mexico, Albuquerque, NM, United States, 2Cardiothoracic Surgery Section, New Mexico VA Health Care System/University of New Mexico, Albuquerque, NM, United States, 3Div. of Pulmonary, Critical Care and Sleep, New Mexico VA Health Care System/Univ of New Mexico, Albuquerque, NM, United States, 4Div. of Pulmonary, Critical Care and Sleep, New Mexico VA Health Care System, Albuquerque, NM, United States.
Introduction: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and positive airway pressure (PAP) is the treatment of choice. While AASM has established practice parameters for the use of PAP devices to titrate and treat adults with OSA, wide variations exist in the prescription of PAP and over-titration is a potential problem that can lead to serious complications, such as spontaneous pneumothorax (PTX). We report a case of PTX caused by high PAP therapy for OSA.
Case: The patient is a 64 y/o white male with history of NSTEMI, hypertension and hyperlipidemia, who presented to the ER with right pleuritic chest pain and dyspnea. Review of system was otherwise unremarkable. Physical exam was notable for decreased breath sound on the right. CXR showed a right moderate PTX, a pigtail chest tube was placed with complete reexpansion of the lung. Subsequent chest CT scan showed no significant intra-pulmonary pathologies. The chest tube was removed after two days, follow up CXR showed no recurrence and patient was discharged home. On the following morning, he presented again in the ER with recurrence of symptoms and PTX, requiring another chest tube placement. Further history reveal that he was recently diagnosed with OSA and placed on PAP therapy at an outside facility, which he resumed at night following discharge. Interrogation of the device indicated settings of adaptive support ventilation (ASV) mode with EPAP of 15 and PS of 5-10 cmH2O. Such high settings likely caused his PTX, as no other contributing factors could be identified. The settings were reduced to EPAP of 8 and PS of 4-9 cm H2O. Patient was discharge home with the chest tube/Pneumostat. He was observed on the new settings with no evidence of recurrent air leak prior to chest tube removal. Follow up full PFT 6 weeks later showed normal spirometry, lung volumes and DLCO. Patient resumed and tolerated the new PAP settings well. Download 2 weeks later showed good adherence with AHI of 3.0. No recurrence of PTX since.
Conclusion: Excessive PAP therapy for OSA can increase the risk of PTX, a potentially life-threatening complication. It is important for clinicians to ascertain whether or not patient is on PAP treatment as a part of the routine evaluation for PTX. In our experiences, high PAP is rarely indicated. Measures should be taken to avoid the use of excessive PAP and reduce potential risks for such complications.