Epistaxis, medical history, and the nasopulmonary reflex: what is clinically relevant?

Posterior epistaxis and its management are associated with increased morbidity and sudden death. A "nasopulmonary reflex," changes in pulmonary function induced by packing, has been postulated to cause hypoxia and lead to the reported morbidities. However, no study has followed patients prospectively to associate complications with oxygen status. Continuous pulse oximetry monitoring of 19 patients hospitalized with posterior packing was undertaken to document the incidence and extent of oxygen desaturation, and to correlate complications with O2 status and historical factors. A further aim was to clarify the clinical relevance of the nasopulmonary reflex. In 1200 hours of monitoring, desaturations to less than 90% were observed on only two occasions: one self-limited episode in an actively bleeding patient and one major hypoxic event with respiratory arrest in an alcoholic patient under sedation for delirium tremens. Complications, while uncommon, were more appropriately ascribed to rebleeding or underlying medical problems than to primary O2 status. The nasopulmonary reflex, as previously described in terms of a primary drop in O2, therefore seems clinically irrelevant. Early surgery for posterior epistaxis is not warranted on the basis of maintenance of adequate oxygenation alone.