Will high flow oxygen (O2) therapy help resolve pneumoperitoneum, similar to its use in pneumothorax?

High-Flow Oxygen Therapy Is Not Recommended for Resolving Pneumoperitoneum

High-flow oxygen therapy, which can help resolve pneumothorax, is not indicated or recommended for the treatment of pneumoperitoneum based on current evidence. 1, 2

Differences Between Pneumothorax and Pneumoperitoneum

Pneumothorax

• Air collection in the pleural space
• High-flow oxygen (10-15 L/min) increases reabsorption rate four-fold by:
  • Creating a pressure gradient that enhances nitrogen washout
  • Replacing trapped air with oxygen that is more readily absorbed 2

Pneumoperitoneum

• Air collection in the peritoneal cavity
• Different physiological mechanism than pneumothorax
• No evidence supporting oxygen therapy for resolution 3, 4

Management of Pneumoperitoneum

Etiology-Based Approach

1. Iatrogenic (post-surgical)

   • Most common after laparoscopic procedures
   • Typically resolves spontaneously within days
   • Observation is usually sufficient 4

2. Pathological (perforation)

   • Requires surgical intervention to address the underlying cause
   • High-flow oxygen would not address the primary problem 3

3. Secondary to thoracic air leak

   • When pneumoperitoneum occurs secondary to pneumothorax/pneumomediastinum
   • Treatment should focus on the primary thoracic air leak
   • Conservative management may be appropriate if patient is stable 3

Evidence Against Oxygen Therapy for Pneumoperitoneum

The 2021 guidelines on enhanced recovery after pulmonary lobectomy specifically state that there is insufficient evidence to support the routine use of prophylactic high-flow oxygen therapy even for pulmonary complications, let alone for pneumoperitoneum 1.

While high-flow oxygen is recommended for pneumothorax to increase reabsorption rates 2, this physiological mechanism doesn't apply to the peritoneal cavity in the same way due to:

• Different vascular supply
• Different absorption mechanisms
• Different pressure dynamics

Clinical Management Recommendations

1. For stable, asymptomatic pneumoperitoneum (e.g., post-laparoscopy or secondary to thoracic air leak without peritonitis):

   • Conservative management with observation
   • No indication for high-flow oxygen therapy 3

2. For symptomatic or pathological pneumoperitoneum:

   • Surgical evaluation and intervention to address underlying cause
   • Focus on treating primary pathology rather than attempting to accelerate air resorption 4

3. For pneumoperitoneum secondary to pneumothorax:

   • Treat the primary pneumothorax with appropriate measures including high-flow oxygen
   • The pneumoperitoneum will typically resolve once the source is addressed 3

Potential Complications of Unnecessary Oxygen Therapy

• Oxygen toxicity with prolonged high-flow administration
• False sense of security delaying appropriate surgical intervention
• Resource utilization without evidence of benefit

Key Takeaway

Unlike pneumothorax, where high-flow oxygen therapy is a standard treatment to accelerate air resorption, there is no evidence supporting this approach for pneumoperitoneum. Management should focus on addressing the underlying cause rather than attempting to accelerate resorption through oxygen therapy.