High-Flow Nasal Cannula Oxygen Therapy in Pulmonary Fat Embolism-Case Report

Case Report

Austin Crit Care Case Rep. 2021; 5(1): 1019.

High-Flow Nasal Cannula Oxygen Therapy in Pulmonary Fat Embolism-Case Report

Ferrao JB1*, Maria Amaral2, Marta Ilharco2, Jose Casimiro3, Margarida Santos4 and Nuno Germano5

1Department 2.3 Internal Medicine, Santo Antonio dos Capuchos Hospital, Center Hospitalar University Lisbon Central, Portugal

2Department 1.4 Internal Medicine, Center Hospitalar University Lisbon Central, Portugal

3Center Hospitalar University Lisbon Central, Intensive Care Unit Curry Cabral Hospital, Portugal

4Anatomical Pathology Resident, Center Hospitalar University Lisbon Central, Portugal

5Internal Medicine Specialist, Center Hospitalar University Lisbon Central, Portugal

*Corresponding author: Joana Branco Ferrao, Department 2.3 Internal Medicine, Santo António dos Capuchos Hospital, Center Hospitalar University Lisbon Central, Alameda Santo António dos Capuchos, Serviço de Medicina Interna, 1169-050 Lisboa, Portugal

Received: December 02, 2020; Accepted: January 04, 2021; Published: January 11, 2021


Fat Embolism Syndrome (FES) is the systemic manifestation of fat emboli in the circulation-a rare and potentially lethal complication of trauma, seen mostly after long bone fractures. Hypoxia is the most common and earliest feature of FES, followed by Central Nervous System manifestations. Other than supportive treatment, no exclusive and defined treatment approach has yet been identified. In the ICU, there has been an increased use of High Flow Nasal Cannula Oxygen (HFNC) in situations of acute respiratory failure. In the case under analysis, respiratory failure with hypoxemia occurs in a young patient with risk factors for fat pulmonary embolism, who responded well to supportive care.

Keywords: Hypoxia; Fat embolism; Tibial Factures; Non-Invasive Ventilation; Lung Injury


FES: Fat Embolism Syndrome; FE: Fat Embolism; HFNC: High Flow Nasal Cannula Oxygen


FES is an infrequent complication related to long bone fracture with a constellation of signs and symptoms depending whether there is systemic evolvement or solely lung injury with marked hypoxia and need for respiratory support. Diagnosis is mainly clinical with no formal standard treatment and delayed approach may have devastating consequences. We report a case of Fat Embolism (FE) after delayed reaming of a tibial fracture, evolving to respiratory failure and need for non-invasive ventilation. An overview of the literature and discussion of the features is provided.

Case Report

An 18-year-old male patient with a history of asthma was presented to the emergency room after a high-speed injury. Despite initial loss of consciousness, neurologic findings were normal on arrival. First clinical findings revealed right leg trauma with limb edema, hemodynamic stability, and no respiratory alterations. Head CT-scan was normal and radiography of right leg showed a tibial fracture. Limb immobilization was performed and 3 days after admission the patient underwent surgical intervention with closed reduction and reaming of the right tibia.

Shortly after surgery, he developed symptoms of chest pain and dyspnoea. The patient was hemodynamically stable with a heart rate of 109bpm, respiratory rate of 30cpm and oxygen saturation of 93% with oxygen therapy of 6 L/min through facial mask. Arterial blood gas, on 6L/min of oxygen, revealed pH 7.43, pO2 60.1 mmHg, pCO2 39 mmHg, Sat O2: 91%, HCO3 26.4 mmol/L, Lactate 2.2 mmol/L, PaO2/FiO2 of 136. There was no evidence of external bleeding or circulatory instability. Chest radiography revealed bilateral interstitial infiltrates (Figure 1), followed by CT-Angiography of the chest that ruled out pulmonary thromboembolism, but revealed extensive ground glass opacities (Figures 2A,2B,2C). Due to acute respiratory distress, the patient was admitted to the ICU, followed by non-invasive respiratory support with HFNC with significant improvement. Blood analysis showed: Hemoglobin 9.8g/dL, without leucocytosis, platelets 132000 U/L, Dimers of 1217 U/L, Calcium of 7.7mmol/L, LDH 404 U/L, CK 2855 U/L and a myoglobin of 831.5 ng/mL. Due to the unclear etiology of the CT scan findings, he was started on empiric antibiotics, stopped 24h later, due to noncompelling evidence of infection. Etiological investigation ensued: cultural exams (blood cultures, Mycoplasma and Chlamydia blood antigens, Legionella and Pneumococcus urinary antigens), serologies (HIV 1-2), and auto-immunity studies (Anti-citrulline, Rheumatoid factor, Anti-neutrophil cytoplasm, Anti-MBG, Antinuclear, antidsDNA, Anti-nucleosome antibodies and ENA), came back negative. Bronchofibroscopy with bronchoalveolar lavage cytology revealed innumerous lipid-laden macrophages-alveolar macrophages with cytoplasmic fat inclusions (Figures 3,4). Oil Red O stains neutral triglycerides and lipids, indicating lipid accumulation in the cytoplasm of alveolar macrophages. The diagnoses of FE after nailing of isolated right tibial fracture was assumed, with favourable radiological evolution and almost complete clearance of infiltrates by day 5. Patient was weaned from HFNC after 3 days and later transferred to the orthopedics ward, with an uneventful hospitalization.