Air regurgitation through the nasolacrimal duct in a patient on bi-level positive airway pressure therapy

Akhil Paul; Susana Mathew; Bindu Thomas

doi:10.4103/jalh.jalh_40_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 76-78

Air regurgitation through the nasolacrimal duct in a patient on bi-level positive airway pressure therapy

Akhil Paul¹, Susana Mathew², Bindu Thomas³
¹ Department of Pulmonary Medicine, MOSC Medical Mission Hospital, Thrissur, Kerala, India
² Department of Otorhinolaryngology, MOSC Medical Mission Hospital, Thrissur, Kerala, India
³ Department of Ophthalmology, MOSC Medical Mission Hospital, Thrissur, Kerala, India

Date of Submission	17-Dec-2022
Date of Acceptance	20-Jan-2023
Date of Web Publication	02-May-2023

Correspondence Address:
Dr. Akhil Paul
Department of Pulmonary and Sleep Medicine, MOSC Medical Mission Hospital, Kunnamkulam, Thrissur - 680 503, Kerala
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jalh.jalh_40_22

Abstract

Positive airway pressure therapy is usually a well tolerated mode of treatment used for managing patients with various diseases where either oxygenation or ventilation is compromised. Air regurgitation through the naso lacrimal duct (NLD) is a rare complication of positive airway pressure therapy. There are multiple valves in the nasolacrimal duct to prevent the retrograde airflow from the nasal cavity to the lacrimal sac, under normal physiological conditions. Failure of this multi level valve system will lead to the retrograde air flow from the nasal cavity to reach the lacrimal puncta via the nasolacrimal duct. Valve insufficiency by birth or due to a prior procedure done at this region could be the underlying cause for this complication. In this case report, we discuss about the appearance of air regurgitation in a patient with chronic obstructive pulmonary disease on bi-level positive airway pressure (BiPAP) therapy and we also discuss on the causes for this complication and the various treatment modalities to manage this condition.

Keywords: Air regurgitation, nasolacrimal duct, positive airway pressure therapy

How to cite this article:
Paul A, Mathew S, Thomas B. Air regurgitation through the nasolacrimal duct in a patient on bi-level positive airway pressure therapy. J Adv Lung Health 2023;3:76-8

How to cite this URL:
Paul A, Mathew S, Thomas B. Air regurgitation through the nasolacrimal duct in a patient on bi-level positive airway pressure therapy. J Adv Lung Health [serial online] 2023 [cited 2023 Jun 10];3:76-8. Available from: https://www.jalh.org//text.asp?2023/3/2/76/375539

Introduction

Positive airway pressure therapy is usually a well-tolerated mode of treatment used for managing patients with various diseases where either oxygenation or ventilation is compromised. Air regurgitation through the nasolacrimal duct (NLD) is a rare complication of positive airway pressure therapy. There are multiple ways to manage this condition. In this case report, we discuss the appearance of air regurgitation in a patient with chronic obstructive pulmonary disease (COPD) on bi-level positive airway pressure (BiPAP) therapy and we also discuss on the causes for this complication and the various treatment modalities to manage this condition.

Case Report

A 70-year-old elderly man, a known case of COPD presented to us with low-grade intermittent fever, productive cough with thick yellowish sputum, and worsening of breathlessness with wheeze for a week. His breathlessness had worsened in the past 4 days and he was in significant respiratory distress at the presentation. He was a current smoker and he was also on medications for diabetes mellitus and systemic hypertension. He had an extensive bilateral wheeze and his SpO2 was 80% at presentation. His systemic blood pressure was 150/90 mmHg, assessed at the right brachial artery. His blood counts showed an increased total leukocyte count of 15,000/mm³ with a neutrophilic predominance and his chest X-ray Antero-posterior (AP) view showed bilateral hyperinflated lungs with prominent bronchovascular markings. His blood sugar and serum electrolyte levels were within the normal range.

He was initiated on bronchodilator nebulizations ipratropium 0.5 mg and 2.5 mg salbutamol as a combination of total 3 ml, which was repeated after 1 h. Nebulized budesonide 0.5 mg and intravenous hydrocortisone 200 mg were also given as stat doses and he was intiated on IV antibiotic (amoxicillin and clavulanic acid) as well. After 2 h of treatment, he continued to have bilateral wheeze and his sensorium worsened to a Glasgow Coma Scale of 10/15. An arterial blood gas analysis showed an acute on chronic type II respiratory failure with a pH of 7.10, pCO2 of 80 mmHg, Hco3-of 32 mmol/L, and lactate was 2.4 mmol/L. He was initiated on BiPAP device with an inspired pressure inspiratory positive airway pressure of 15 cm H2O and an expiratory pressure expiratory positive airway pressure of 5 cm H2O, through a face mask. On day 2, on initiating him on noninvasive ventilation, continuous bubbling appeared near the medial canthus of his left eye [Figure 1]. The bubbling was synchronized with the inspiration. Air regurgitation through the nasolacrimal duct was found to be the cause of the bubbling. There was no history of any procedure or surgery done at this region.

Figure 1: Air regurgitation through NLD causing bubbling at the lacrimal puncta. NLD: Naso lacrimal duct

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After the initial improvement, the sensorium of the patient had further deterioration along with increase in the pCO2 level. Considering the clinical deterioration on noninvasive ventilation and the presence of air regurgitation through the NLD, the need for invasive ventilation was discussed with the relatives. However, they decided not to intubate or resuscitate the patient when the need arises, after understanding the possible consequences, including the mortality. Later, the patient succumbed to his illness.

Discussion

Nasolacrimal air regurgitation is an uncommon complication of positive airway pressure (PAP) therapy. There are multiple valves in the nasolacrimal duct to prevent the retrograde airflow from the nasal cavity to the lacrimal sac, under normal physiological conditions. These valves are [Figure 2]:

Figure 2: Valves of the Naso-Lacrimal Duct

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The valves of Hasner at the inferior tip of the NLD
The valves of Taillefer and the spiral valve of Hyrti within the NLD
The valves of Krause near the sac-duct junction
The valves of Rosenmuller at the sac-common canaliculus junction
The valves of Bochdalek and Foltz at the superior and inferior puncta.^[1]

Failure of this multi-level valve system will lead to the retrograde airflow from the nasal cavity to reach the lacrimal puncta through the nasolacrimal duct. The valve insufficiency could be due to embryological defects or agenesis, which occurs before the 8 month of gestation.^[2] Acquired causes for air regurgitation through the NLD are:

Conjunctivodacryocystorhinostomy and dacryocystorhinostomy using Lester-Jones tube insertion and silicon stent deployment
Positive airway pressure therapy.^[3]

There are various modalities to manage this complication during PAP therapy, which includes:

Using a total face mask^[4]

Hasner's valve reinforcement using a nonabsorbable material
Bulking agent injection around the orifice
Nasopharyngeal airway (nasal trumpet) usage for nocturnal self-administration.^[5]
Placement of a punctum plug.^[6]
Decreasing the CPAP pressure
Change to other options, including a mandibular advancement device.

Wrede et al., in their case report, had described managing the nasolacrimal retrograde air regurgitation during CPAP therapy successfully using a total face mask.^[4] By covering the eyes, a total face mask delivered equal pressure on both sides of the lacrimal system. Göktas et al. successfully managed their 32-year-old patient with advanced Duchenne muscular dystrophy in whom continuous PAP ventilation therapy had led to regurgitation of air through the right NLD causing epiphora and keratoconjunctivitis sicca on that side, by reversibly occluding the lower lacrimal duct with a punctum plug flow regulator.^[6] Yang et al., in their case report, described a simple and novel intervention of inserting a gel foam patch in the lacrimal sac of a patient with obesity hypoventilation syndrome, when he developed symptomatic air regurgitation through the NLD during BiPAP therapy, due to a reconstructive surgery which he had undergone in the past for NLD obstruction.^[7] All these novel interventions were proven successful at 4^th week of follow-up. Intubation and initiation of invasive ventilation are a practical option to manage this condition in a critically ill patient like we had.

Conclusion

Air regurgitation through the nasolacrimal duct is an uncommon complication of positive airway pressure therapy. Valve insufficiency by birth or due to a prior procedure done at this region could be the underlying cause for this complication. There are many surgical and nonsurgical modalities to manage the same.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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