Pneumocephalus: A Complication of Continuous Positive Airway Pressure after Trauma

doi:10.1378/chest.78.4.656

Chest

Volume 78, Issue 4, October 1980, Pages 656-657

https://doi.org/10.1378/chest.78.4.656 Get rights and content

We report an uncommon and potentially dangerous complication of continuous positive airway pressure (CPAP) applied during spontaneous respiration. A patient with multiple fractures and recurrent atelectasis developed pneumocephalus on the seventh day of respiratory therapy with CPAP via a face mask. A fracture of the base of the skull, not recognized despite neurologic and radiologic evaluation at admission, was at the origin of this complication.

Section snippets

Case Report

A 30-year-old man was admitted to the emergency room after an automobile accident. At admission, he had an areactive coma, general areflexia, bilateral miosis, and isocoria. The blood pressure was 70/40 mm Hg, and the heart rate was 130 beats per minute. A right clavicular fracture, a large wound of the right elbow, and an otorrhagia on the right side were diagnosed. Roentgenograms of the skull did not reveal any fracture. Decreased breath sounds were noted over the right upper pulmonary field.

Discussion

Continuous positive airway pressure is a simple, inexpensive, and efficient therapy for the management of atelectasis in nonintubated patients;² however, this technique has several potential side effects. Increased intrathoracic pressure produced by CPAP can decrease venous return and cardiac output,² but this effect is not found constantly.⁴ The impedance to venous return can produce an increase in intracranial pressure; and together with a lowered cardiac output, this may dramatically

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CPAP and PEEP: a perspective
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Continuous positive airway pressure in the prophylaxis of the adult respiratory distress syndrome
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There are more references available in the full text version of this article.

Cited by (45)

Tension Pneumocephalus from Positive Pressure Ventilation Following Endoscopic Skull Base Surgery: Case Series and an Institutional Protocol for the Management of Postoperative Respiratory Distress
2020, World Neurosurgery
Citation Excerpt :
To our knowledge, our 2 cases are the only cases of TP associated with postoperative PPV in the literature. Simple pneumocephalus has previously been described following extended PPV,16 mouth-to-mouth resuscitation,17 induction of anesthesia in a patient with traumatic CSF fistula,18 and with nasal cannulae in pediatric patients.19 Two cases of TP have been attributed to PPV, both in the setting of posttraumatic resuscitation.20,21
Tension pneumocephalus (TP) is a rare but feared complication of endoscopic endonasal skull base surgery. In contrast to simple pneumocephalus, which is common after endoscopic transnasal approaches and managed conservatively, TP represents a neurosurgical emergency and mandates urgent decompression.
Here we present 2 cases of TP as a consequence of positive pressure ventilation following endoscopic endonasal skull base surgery. Both occurred during resuscitation for postoperative hypoxia. These cases prompted the development of an institution-wide protocol to identify and manage patients at risk of TP after extended skull base approaches.
To our knowledge, these are the only such cases of postoperative TP following positive pressure ventilation in the literature.
from toothpick to intraparenychmal otogenic pneumocephalus: A case report
2020, World Neurosurgery
Citation Excerpt :
Reports of CPAP-induced or exacerbated pneumocephalus exist, but none have been spontaneous otogenic. One case was associated with meningitis from an oral cavity organism,14 1 with sinus wall osteomyelitis,15 1 occurred in the setting of basal skull fracture from craniofacial trauma,16 and 1 occurred in the context of distant craniofacial trauma and ventriculoperitoneal shunt placement.17 Presentation of otogenic pneumocephalus in the literature has included headache most commonly, followed by aphasia, otorrhea, rhinorrhea, tinnitus, meningeal signs, hemiparesis, vomiting, and visual changes.1,18,19
Intracranial pneumocephalus, the accumulation of air, occurs most frequently from trauma, tumor, cranial surgeries, or infection. Intraparenchymal otogenic pneumocephalus is a rare but well-documented development. We describe a patient who developed pneumocephalus in the context of eardrum perforation secondary to toothpick use for ear wax.
An 86-year-old female presented to the emergency room with a 1-day history of dysarthria and a few days of cough and sneezing. History revealed she had recently been advised to avoid Q-Tips to clean her ears and instead was using toothpicks. She denied otalgia or otorrhea and had no signs of infection near the ear. On otoscopic examination, the right tympanic membrane was perforated. On head computed tomography, she was found to have a large right temporal pneumocephalus extending from the petrous bone. Magnetic resonance imaging of the brain revealed a defect in the right tegmen. She was started on empiric antibiotics and subsequently taken to the operating room for craniotomy and repair of bony and dural defects.
Otogenic pneumocephalus is a rare occurrence. This is the first reported case of pneumocephalus related to self-induced middle ear trauma with a toothpick that ultimately required craniotomy for repair.
Middle ear pressure during sleep and the effects of continuous positive airway pressure
2015, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Citation Excerpt :
A study conducted in guinea pigs demonstrated that elevating MEP with air up to 250 daPa had no effect on auditory thresholds measured by auditory brainstem response (ABR) [8]. While it appears that hearing is likely not significantly affected in most individuals, there have been rare reports of tympanic membrane rupture, pneumocephalus, and tension pneumocranium with CPAP use [9–12]. Although rare, these findings should prompt caution with CPAP use following head trauma, rhinologic or otologic surgery, and particularly following intradural skull base procedures.
Prior studies evaluating Eustachian tube physiology, baseline middle ear pressure (MEP), and the effects of continuous positive airway pressure (CPAP) have been performed on awake patients. No study to date has specifically investigated MEP during sleep despite the fact that the average individual spends a third of their lifetime sleeping. The primary objectives of the current study are to quantify normal physiologic MEP during sleep and to evaluate the effects of escalating CPAP levels.
Prospective observational study at a tertiary academic referral center evaluating serial tympanometry on sleeping adult patients during polysomnography. MEP was recorded awake, at 1-hour intervals during diagnostic polysomnography, and at all CPAP levels during titration. Changes in MEP with duration of sleep and escalating CPAP levels were analyzed.
Ten adults were included (4 females; 6 males; mean age 58 years). The mean MEP while awake was 3 decapascals (daPa). The mean MEP during sleep without CPAP rose steadily from 14 daPa at 1 hour to 41 daPa at 4 hours (r = 0.52; p < 0.001). The mean MEP during sleep at a CPAP level of 5 cm of water was 54 daPa. The mean MEP rose steadily with increasing CPAP levels, and was 104 daPa at 10 cm of water, (r = 0.82; p < 0.001). The mean MEP during sleep without CPAP was 26 daPa, which was significantly lower than the mean MEP during sleep with CPAP between 5–10 cm H₂O (p < 0.01).
MEP naturally increases with duration of sleep. CPAP therapy causes a supraphysiologic elevation in MEP that rises with increasing pressure levels. These findings may help guide future studies examining the safety of CPAP following otologic surgery and the potential therapeutic benefit in patients with chronic middle ear disease.
Complications of Managing the Airway
2013, Benumof and Hagberg's Airway Management
Complications of Managing the Airway
2012, Benumof and Hagberg's Airway Management: Third Edition
Pneumocephalus with BiPAP use after transsphenoidal surgery
2012, Journal of Clinical Anesthesia
Citation Excerpt :
There is one report of air regurgitation into the eye after dacryocystorhinostomy [10] and another report of pneumocephalus in a patient with a spontaneous CSF leak [11]. Iatrogenic pneumocephalus and/or subcutaneous emphysema after head trauma has been described in a number of case reports secondary to CPAP or even bag mask ventilation [12-15]. Sequelae in these cases vary in severity from complete resolution to persistent neurological deficits.
While the benefits of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) for patients with obstructive sleep apnea are well described, reports in the literature of complications from its use are rare. A patient who received postoperative BiPAP after undergoing transsphenoidal craniopharyngioma resection developed severe pneumocephalus and unplanned intensive care unit admission. Although the pneumocephalus resolved with conservative management over two weeks, we propose caution in the use of CPAP postoperatively in patients undergoing procedures of the head and neck.

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: From the Surgical Intensive Care Unit, Institute of Anesthesiology, Hôpital Cantonal, Geneva, Switzerland

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Chest

Selected ReportsPneumocephalus: A Complication of Continuous Positive Airway Pressure after Trauma

Section snippets

Case Report

Discussion

Chest

CPAP and PEEP: a perspective

Anesthesiology

Continuous positive airway pressure in the prophylaxis of the adult respiratory distress syndrome

Surg Gynecol Obstet

Selected Reports
Pneumocephalus: A Complication of Continuous Positive Airway Pressure after Trauma