Abstracts

Rationale: Respiratory insufficiency during seizures often requires emergency airway and breathing support. Deaths have occurred in the EMU associated with seizure monitoring. Psychogenic non-epileptic attacks (PNEAs) demonstrate clinical semiologies that closely mimic epileptic seizures (ES) in patients with epilepsy. We sought to characterize apparent respiratory compromise in patients with PNEA undergoing in-hospital video-EEG monitoring. Methods: The EMU records of 175 patients were retrospectively identified from a tertiary care referral center, between 4/1/2010 to 4/1/2011. All patients were diagnosed by an epileptologist from in-patient video-EEG monitoring following capture of the habitual event. Records were reviewed for any symptoms of respiratory compromise during seizures recorded while hospitalized. Subjective symptoms of respiratory difficulties were noted and objective evidence of stridor, respiratory distress, oral airway manipulation, and oxygen use were analyzed and characterized. Results: 68/175 (39%) patients had epilepsy, 79/175 (45%) had PNEA, 3/175 (2%) had both PNEA and epilepsy and 25/175 (14%) had no recorded attacks during monitoring. 4 patients had return EMU visits after having no attacks recorded. 3/4 had attacks upon secondary admission and received a diagnosis of epilepsy (N=2) or PNEA (N=1). 67/68 PNEA patients were admitted only once. 2 epilepsy patients returned for repeat EMU visits. 12/79 (15%) PNEA patients, compared with 3/68 (4%) epilepsy patients had respiratory compromise during their events (p= 0.0315). All PNEA patients were receiving AEDs upon admission. 1/12 (8%) PNEA patients reported prior intubations (N=9) for presumed respiratory failure with the episodes representative of the outpatient attacks during vEEG. A near intubation occurred in 1 patient by a first-responder during a typical PNEA in the EMU. 2/79 (3%) PNEA patients, compared with 2/68 (3%) epilepsy patients, had oxygen applied at the time of the episode (p=0.8801). Conclusions: Apparent respiratory compromise in PNEA patients is present in a significant minority with a prevalence that is comparable to those with epileptic seizures. Interventions for respiratory symptoms are similar between those with ES and PNEA. Due to the potential for morbidity and mortality associated with overtreatment in patients with PNEA, highlighting respiratory compromise in the EMU records is crucial for rapid identification by first-responders.