Fatal brain gas embolism during non-invasive positive pressure ventilation

Gas embolism is a dreaded complication following invasive medical procedures, traumatic lung injury and decompression accidents. We report a case of fatal gas embolism following the use of non-invasive ventilation (NIV) with bilevel positive airway pressure (BiPAP). The patient initially underwent left bronchial artery embolisation for massive haemoptysis in the context of severe tuberculotic sequels. Under NIV and after heavy coughing he became hemiparetic and his level of consciousness suddenly dropped. Computed tomography of the brain showed multiple air embolism and ischaemic lesions were confirmed by magnetic resonance imaging. Echocardiographic investigations showed no intracardiac defect. Vasculo-pulmonary abnormalities in the context of heavy coughing and non-invasive ventilation may have played a major role in the occurrence of this event. New neurological events in a patient with tuberculotic sequels or any known vascular pulmonary abnormalities and NIV should raise the suspicion of brain gas embolism.

[1]  M. Mirski,et al.  Diagnosis and Treatment of Vascular Air Embolism , 2007, Anesthesiology.

[2]  V. Gissot,et al.  Embolie gazeuse malgré une ventilation protectrice au cours du syndrome de détresse respiratoire aiguë , 2006 .

[3]  L. Argaud,et al.  Inactive tuberculosis cavity responsible for fatal cerebral air embolism , 2006, Intensive Care Medicine.

[4]  D. Gommers,et al.  In vivo evaluation of the inhibitory capacity of human plasma on exogenous surfactant function , 2006, Intensive Care Medicine.

[5]  F. Mccool,et al.  Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines. , 2006, Chest.

[6]  G M Hutchins,et al.  Volume of air in a lethal venous air embolism. , 2001, Anesthesiology.

[7]  A. Ho,et al.  Systemic air embolism after lung trauma. , 1999, Anesthesiology.

[8]  R. Giebler,et al.  Effect of positive end-expiratory pressure on the incidence of venous air embolism and on the cardiovascular response to the sitting position during neurosurgery. , 1998, British journal of anaesthesia.

[9]  S. Hung,et al.  Cerebral air embolism complicating bilevel positive airway pressure therapy. , 1998, The European respiratory journal.

[10]  J. Hammon,et al.  Emboli and Neuropsychological Outcome Following Cardiopulmonary Bypass , 1996, Echocardiography.

[11]  B A Peretz,et al.  Gas embolism in obstetrics and gynecology. A review. , 1996, The Journal of reproductive medicine.

[12]  C. Tommasino,et al.  Cerebral ischemia after venous air embolism in the absence of intracardiac defects. , 1996, Journal of neurosurgical anesthesiology.

[13]  D. Annane,et al.  Kinetics of Elimination and Acute Consequences of Cerebral Air Embolism , 1995, Journal of neuroimaging : official journal of the American Society of Neuroimaging.

[14]  S. Allen,et al.  Venous air embolism in patients with pulmonary barotrauma. , 1994, Critical care medicine.

[15]  T. Marcy,et al.  Barotrauma: detection, recognition, and management. , 1993, Chest.

[16]  L. Spätling.  Magnesium in Geburtshilfe und Frauenheilkunde , 1993 .

[17]  W. Lien,et al.  Detection of patent foramen ovale by contrast transesophageal echocardiography. , 1992, Chest.

[18]  M. Howie,et al.  REDUCTION OF THE CATECHOLAMINE RESPONSE TO CABG SURGERY BY CLONIDINE , 1991 .

[19]  J. Judson,et al.  Cerebral arterial air embolism associated with coughing on a continuous positive airway pressure circuit , 1991, Critical care medicine.

[20]  J. Brock‐Utne,et al.  Intraoperative ventilator-induced right-to-left intracardiac shunt. , 1991, Anesthesiology.

[21]  J. Marini,et al.  Systemic Gas Embolism Complicating Mechanical Ventilation in the Adult Respiratory Distress Syndrome , 1989 .

[22]  M. Palazzo,et al.  Air embolism during total hip replacement: comparison of two surgical techniques. , 1989, British journal of anaesthesia.

[23]  R. Beran,et al.  The role of computed tomography in the assessment of neurologic sequelae of decompression sickness. , 1988, Archives of neurology.

[24]  A. Dutka.  A review of the pathophysiology and potential application of experimental therapies for cerebral ischemia to the treatment of cerebral arterial gas embolism. , 1985, Undersea biomedical research.

[25]  P. Guéret,et al.  Contrast echocardiographic visualization of cough-induced right to left shunt through a patent foramen ovale. , 1984, Journal of the American College of Cardiology.

[26]  B D Butler,et al.  The lung as a filter for microbubbles. , 1979, Journal of applied physiology: respiratory, environmental and exercise physiology.

[27]  H. Cranz.  [Air embolism and spontaneous pneumothorax as an avoidable complication of artificial pneumothorax]. , 1950, Acta tuberculosea Scandinavica.