Clinical Note |

An Adverse Effect of Positive Airway Pressure on the Upper Airway Documented With Magnetic Resonance Imaging

Robert J. Fleck Jr, MD; Mohamed Mahmoud, MD; Keith McConnell, MS; Sally R. Shott, MD; Ephraim Gutmark, PhD; Raouf S. Amin, MD
JAMA Otolaryngol Head Neck Surg. 2013;139(6):636-638. doi:10.1001/jamaoto.2013.3279.
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Importance Positive pressure air is used during basic life support to provide respirations and applied as continuous positive airway pressure to maintain a patent airway during sleep or anesthesia. These functions are more critical in children with obstructive sleep apnea, who often have smaller airway dimensions and increased airway collapsibility.

Observations We report 2 cases of boys with Down syndrome and a history of obstructive sleep apnea in whom adverse narrowing of the retroglossal airway is caused by continuous positive airway pressure applied via face mask as documented with magnetic resonance imaging.

Conclusions and Relevance Administration of continuous positive airway pressure by means of face mask to patients can result in adverse effects on the airway patency by pushing the tongue posteriorly. Awareness of this effect on patients with open mouths and large tongues, as present in Down syndrome, is important for sleep apnea treatment, anesthesia, and emergency respiratory support. Generalization of our observation is not possible at this time. Additional prospective studies of the effects of continuous positive airway pressure on airway patency in sedated and/or anesthetized children are required to confirm our anecdotal observations.

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Graphic Jump Location

Figure. Patients 1 and 2. All magnetic resonance images were obtained with 3-dimensional fast spin echo (proton density) with end inspiratory respiratory gating. Patient 1: A, With 0 cm H2O continuous positive airway pressure (CPAP) via face mask. Note patency between the oral airway and the retroglossal airway (arrowhead) and the tongue in neutral position with the mouth open. B, With 15 cm H2O CPAP via face mask, the retroglossal airway is narrowed by the tongue (short arrow), which is pushed back by the CPAP. Note the convexity of the anterior superior portion of the tongue (long arrow) and the occlusion of the oral airway (arrowhead) by opposition of the tongue and soft palate. Patient 2: C, With 15 cm H2O CPAP via face mask with the mouth open, the retroglossal airway is narrowed by the tongue (short arrow), which is pushed back by oral CPAP pressure. Similar to patient 1, there is convexity (long arrow) of the anterior superior tongue. D, With 15 cm H2O CPAP via face mask with the mouth closed, the pressure opens the nasopharyngeal airway (small arrows) and retroglossal airway (short arrow).




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