title: Pneumothorax as a Complication of Apnea Testing for Brain Death.
abstract: Pneumothorax is an under-recognized complication of apnea testing performed as part of the neurological determination of death. It may result in hemodynamic instability or even cardiac arrest, compromising ability to declare brain death (BD) and viability of organs for transplantation. We report three cases of pneumothorax with apnea testing (PAT) and review the available literature of this phenomenon.
  
  
  
  Series of three cases supplemented with a systematic review of literature (including discussion of apnea testing in major brain death guidelines).
  
  
  
  Two patients were diagnosed with PAT due to immediate hemodynamic compromise, while the third was diagnosed many hours after BD. An additional nine cases of PAT were found in the literature. Information regarding oxygen cannula diameter was available for nine patients (range 2.3-5.3 mm), and flow rate was available for ten patients (mean 11 L/min). Pneumothorax was treated to resolution in the majority of patients (n = 8), although only six completed apnea testing following diagnosis/treatment of pneumothorax and only three patients became organ donors afterward. Review of major BD guidelines showed that although use of low oxygen flow rate (usually ≤ 6 L/min) during apnea testing is suggested, the risk of PAT was explicitly mentioned in just one.
  
  
  
  Development of PAT may adversely affect the process of BD determination and could limit the opportunity for organ donation. Each institution should have preventive measures in place.
authors.affiliation: Department of Neurology, St. Louis University School of Medicine, 1438 S Grand Blvd, St Louis, MO, USA.
authors.forename: Lauren Elizabeth
authors.initials: LE
authors.lastname: Gorton
authors.affiliation: Department of Neurology, Washington University in St Louis School of Medicine, St Louis, MO, USA.
authors.forename: Rajat
authors.initials: R
authors.lastname: Dhar
authors.affiliation: Mid-America Transplant, St Louis, MO, USA.
authors.forename: Lindsey
authors.initials: L
authors.lastname: Woodworth
authors.affiliation: Department of Critical Care, Missouri Baptist Medical Center, St Louis, MO, USA.
authors.forename: Nitin J
authors.initials: NJ
authors.lastname: Anand
authors.affiliation: Department of Neurology, St. Louis University School of Medicine, 1438 S Grand Blvd, St Louis, MO, USA.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Hayes
authors.affiliation: Department of Neurology, St. Louis University School of Medicine, 1438 S Grand Blvd, St Louis, MO, USA.
authors.forename: Joanna Isabelle
authors.initials: JI
authors.lastname: Ramiro
authors.affiliation: Department of Neurology, St. Louis University School of Medicine, 1438 S Grand Blvd, St Louis, MO, USA. abhay.kumarjha@gmail.com.
authors.forename: Abhay
authors.identifier: 0000-0002-6966-0918
authors.initials: A
authors.lastname: Kumar
mesh_terms: D000328:Adult; D000368:Aged; D001049:Apnea / Q000175:diagnosis*; D001926:Brain Death / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008297:Male; D011030:Pneumothorax / Q000209:etiology* / Q000628:therapy; D055815:Young Adult
keywords: Apnea testing; Brain death examination; Organ donation; Pneumothorax