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A preterm female infant was born at 28 weeks of gestation, weighing 840 g. She was intubated soon after delivery and diagnosed with respiratory distress syndrome. She required positive pressure ventilation for 10 days, at which time she was extubated and placed on nasal continuous positive airway pressure (CPAP) for apnoea prophylaxis. On day 14 of life, severe apnoea and respiratory distress with deep subcostal retraction were noted. It was decided to intubate the child again, but while preparing her for the procedure, an extensive mass was seen at the nasopharynx (fig 1). This mass was immediately removed, at which time the infant showed dramatic improvement from the apnoea and respiratory distress, and her respiration quickly returned to normal without oxygen or nasal CPAP treatment.

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Figure 1

Extensive blood-tinged secretion from intranasal cavities and nasopharynx.

Preterm infants are at increased risk for developing upper airway obstruction because they are obligate nasal breathers. In addition to increasing the work of breathing, upper airway obstruction can result in spells of apnoea.1 This brief case study should remind physicians and nurses that a blocked nose and/or nasopharynx could be a cause of apnoea in preterm infants on nasal CPAP. The high airflow in non-invasive pressure ventilation, such as nasal cannulas, and the more frequent suctioning can potentially irritate the nasal mucosa, which can present as increased nasal secretion and increased rate of visible blood in nasal secretions, and finally result in upper airway obstruction.2^,3

In conclusion, careful examination and care of the nasal cavities should therefore be routinely performed in all cases of preterm infants on nasal CPAP.