Negative pressure pulmonary edema: report of case series and review of the literature / Edema pulmonar por pressão negativa: relato de casos e revisão da literatura

Abstract Background and objectives: Negative pressure pulmonary edema occurs by increased intrathoracic negative pressure following inspiration against obstructed upper airway. The pressure generated is transmitted to the pulmonary capillaries and exceeds the pressure of hydrostatic equilibrium, causing fluid extravasation into the pulmonary parenchyma and alveoli. In anesthesiology, common situations such as laryngospasm and upper airway obstruction can trigger this complication, which presents considerable morbidity and requires immediate diagnosis and propaedeutics. Upper airway patency, noninvasive ventilation with positive pressure, supplemental oxygen and, if necessary, reintubation with mechanical ventilation are the basis of therapy. Case report: Case 1: Male, 52 years old, undergoing appendectomy under general anesthesia with orotracheal intubation, non-depolarizing neuromuscular blocker, reversed with anticholinesterase, presented with laryngospasm after extubation, followed by pulmonary edema. Case 2: Female, 23 years old, undergoing breast reduction under general anesthesia with oro-tracheal intubation, non-depolarizing neuromuscular blocker, reversed with anticholinesterase,presented with inspiration against closed glottis after extubation, was treated with non-invasiveventilation with positive pressure; after 1 hour, she had pulmonary edema. Case 3: Male, 44 yearsold, undergoing ureterolithotripsy under general anesthesia, without neuromuscular blocker,presented with laryngospasm after laryngeal mask removal evolving with pulmonary edema. Case 4: Male, 7 years old, undergoing crude fracture reduction under general anesthesia withorotracheal intubation, non-depolarizing neuromuscular blocker, presented with laryngospasmreversed with non-invasive ventilation with positive pressure after extubation, followed bypulmonary edema. Conclusions: The anesthesiologists should prevent the patient from perform a forced inspirationagainst closed glottis, in addition to being able to recognize and treat cases of negative pressurepulmonary edema.

Resumo Justificativa e objetivos: O edema pulmonar por pressão negativa ocorre por aumento da pressão negativa intratorácica após inspiração contra via aérea superior obstruída. A pressão gerada é transmitida aos capilares pulmonares e supera a pressão de equilíbrio hidrostático, o que causa extravasamento de líquido para o parênquima pulmonar e alvéolos. Em anestesiologia, situações comuns como laringoespasmo e obstrução de via aérea superior podem desencadear essa complicação, que apresenta considerável morbidade e exige diagnóstico e propedêutica imediatos. A desobstrução das vias aéreas superiores, ventilação não invasiva com pressão positiva, oxigênio suplementar e, se necessário reintubação com ventilação mecânica são a base da terapia. Relato de caso: Caso 1: Masculino, 52 anos, submetido a apendicectomia sob anestesia geral com intubação orotraqueal, uso de bloqueador neuromuscular adespolarizante, revertido com anticolinesterásico; apresentou laringoespasmo após extubação, seguido de edema pulmonar. Caso 2: Feminino, 23 anos, submetida a mamoplastia redutora sob anestesia geral com intubação orotraqueal, bloqueador neuromuscular adespolarizante revertido com anticolinesterásico, apresentou inspiração contra glote fechada após extubação, tratada com ventilação não invasiva com pressão positiva; após uma hora apresentou edema pulmonar. Caso 3: Masculino, 44 anos, submetido a ureterolitotripsia sob anestesia geral, sem bloqueador neuromuscular, apresentou laringoespasmo após retirada de máscara laríngea e evoluiu com edema pulmonar. Caso 4: Masculino, sete anos, submetido a redução cruenta de fratura sob anestesia geral com intubação orotraqueal, uso de bloqueador neuromuscular adespolarizante; apresentou laringo-espasmo revertido com ventilação não invasiva com pressão positiva após extubação, seguidode edema pulmonar. Conclusões: O anestesiologista deve evitar que o paciente faça inspiração forçada contra glotefechada, além de ser capaz de reconhecer e tratar os casos de edema pulmonar por pressãonegativa.

Edema agudo de pulmón por presión negativa secundario a laringoespasmo / Acute lung edema due to negative pressure secondary to laryngospasm

Resumen El edema agudo de pulmón por presión negativa es una forma de edema pulmonar no cardiogénico, potencialmente grave, que suele ocurrir en sujetos sanos jóvenes capaces de generar presiones intratorácicas negativas elevadas al inspirar vigorosamente contra una vía aérea superior obstruida. En adultos la causa más frecuente es el laringoespasmo posextubación en el periodo posoperatorio inmediato. Puede afectar a 0.05-0.1% de los pacientes sanos sometidos a anestesia general. Se comunica el caso de un paciente de 24 años de edad, sin antecedentes patológicos, que acudió al servicio de consulta externa de Cirugía del Hospital Regional Santa Teresa, Comayagua, Honduras, para realizar colecistectomía abierta por colecistitis crónica calculosa agudizada. Se realizó procedimiento quirúrgico sin complicaciones; 15 minutos del periodo posoperatorio inmediato, después de la extubación, el paciente tuvo cuadro clínico de disnea súbita, cianosis y hemoptisis. A la exploración física se encontró hipoxemia, taquipnea (FR = 40 rpm) y crépitos bilaterales en la auscultación. Se realizaron exámenes complementarios y de imagen, concluyendo edema agudo de pulmón. Se inició tratamiento con oxigenoterapia, corticoesteroides y diuréticos durante 72 horas, con lo que evolucionó de forma favorable. Los hallazgos clínicos del edema agudo de pulmón por presión negativa pueden confundirse con una amplia gama de afecciones clínicas, por lo que es de suma importancia realizar el abordaje adecuado y diagnóstico diferencial. El inicio de las medidas terapéuticas oportunas ofrece un pronóstico favorable y generalmente disminución de la mortalidad.

Abstract Acute negative pressure pulmonary edema is a form of potentially serious noncardiogenic pulmonary edema that usually occurs in young healthy subjects capable of generating elevated negative intrathoracic pressures by vigorously inhaling a blocked upper airway. In adults, the most frequent cause is postextubation laryngospasm in the immediate postoperative period. It can present in 0.05-0.1% of healthy patients under general anesthesia. This paper reports the case of a 24-year-old male with no pathological history, who was presented to the general surgery service of the Hospital Regional Santa Teresa, Comayagua, Honduras, to perform open cholecystectomy for chronic cholecystitis. The surgical procedure was performed without complications; 15 minutes of the immediate postoperative period, post-extubation, patient presented clinical manifestations of sudden dyspnea, cyanosis and hemoptysis. On physical examination were found hypoxemia, tachypnea (BR = 40 bfm) and bilateral craniocereus on pulmonary auscultation. Complementary tests and image were performed and NPPE was diagnosed. Treatment with oxygen therapy, corticosteroids and diuretics was started, during 72 hours evolving favorably. The clinical findings of the acute negative pressure pulmonary edema can be confused with a wide range of clinical entities, so it is extremely important to carry out an adequate approach and differential diagnosis. The introduction of appropriate therapeutic measures offers a favorable prognosis and generally a wide decrease in mortality.

Negative pressure pulmonary edema secondary to laryngospasm: a case report / 华西口腔医学杂志

Negative pressure pulmonary edema is a rare complication of general anesthesia. This paper presents a case of acute negative pressure pulmonary edema that occurred during general anesthesia resuscitation. The patient is a young male that underwent bimaxillary surgery under general anesthesia. Laryngospasm spasm ensued after extubation. The treatment for laryngeal spasm retained the smoothness of the nasopharyngal airway, and the pulse oxygen saturation rapidly decreased after anesthesia resuscitation. Pink foam sputum was sucked out from the cavity due to respiratory shortness from mouth and nose. Highly concentrated oxygen was immediately given to assist ventilation and as a symptomatic support (diuretics, hormones), and the condition evidently improved. The diagnosis and treatment of this case suggest that when acute pulmonary edema occurs during general anesthesia resuscitation, negative pressure pulmonary edema should be highly suspected. The first line of treatment is to relieve respiratory tract obstruction. Supplying highly concentrated oxygen to assist positive pressure ventilation is an effective treatment to alleviate pulmonary edema.

Postoperative negative pressure pulmonary edema following repetitive laryngospasm even after reversal of neuromuscular blockade by sugammadex: a case report / 대한마취과학회지

Laryngospasm, an occlusion of the glottis, can occur at any time during anesthesia, and is associated with serious perioperative complications such as hypoxia, hypercabia, aspiration, bronchospasm, arrhythmia, prolonged recovery, cardiac collapse, and eventually catastrophic death. Importantly, postoperative negative pressure pulmonary edema (NPPE) is a rare, but well described life-threatening complication related to acute and chronic upper airway obstruction. Sugammadex well known for affirmatively reducing the postoperative pulmonary complications associated with residual neuromuscular blockade may have an indirect role in triggering the negative intrathoracic pressure by raising a rapid and efficacious respiratory muscle strength in acute upper airway obstruction. Herein, we report a case of postoperative NPPE following repetitive laryngospasm even after reversal of rocuronium-induced neuromuscular blockade using sugammadex.

Edema agudo del pulmón por presión Negativa en el post-operatorio inmediato / Negative Pressure Pulmonary Edema: Case Report

Paciente masculino de 23 años que presenta edema agudo del pulmón, no cardiogénico secundario a presión negativa, en el postoperatorio inmediato

This case is about a male patent, 23 years old, who presented negative pressure pulmonary edema during immediate post-operatve period.

Role of Laryngeal Spasm in Negative Pressure Pulmonary Oedema.

Negative-pressure pulmonary edema (NPPE) is a clinical entity of anaesthesiologic relevance, peri-operatively caused by obstruction of the conductive airways (upper airway obstruction, UAO) due to laryngospasm in approx. 50% of the cases, its early recognition and treatment by the anaesthesiologist is mandatory. Laryngospasm, a brief closure of the vocal cords is not an uncommon peri-operative occurrence. If recognized and managed appropriately, the effects are transient and reversible. However, in rare cases where recognition and management are delayed, the consequences are associated with a high morbidity including desaturation, awareness, negative pressure pulmonary edema, and mortality.

Clinical analysis of ni ne children with acute laryngitis complicated with negative pressure pulmonary edema and changes of inflammatory factors / 中国小儿急救医学

Objective To investigate ht e clinical characteristics and treatment of children with acute laryn gitis comlp icated with negative pressure pulmno ary edema(NPPE),and the changes of inflammatory factosr w ere monitored.Methods Data of 9 cases with acute laryngitis complicated with NPPE in pediatric intensive care unit from August 2010 to March 2015 we re analyzde .The levelso f TNF -αand IL-6 of 8 cases were detected at admission and checked agani forty-eihg t horu s after therapy.Ten children of acute laryngitis wi thotu NPPE were selected as disease cotn rol group, and ten healthy children as normal control group. Results (1)The onset of NPPE varied from 8 minutes to 2 hours following relief of obstruction,and presen-ted with acute respiratory disrt ess, decreased xo ygen saturation, tachycardai , rales on chest auscultation.All thees patients received therapeutic measures icn luding mechna ical ventilation,limiting the fluid input volume. The disappearance of rales on chest auscultation varied from 6 hours to 30 hours.Duration of mechanical ven-tilation was lse s than 48 hours,and all the children were cured.(2) Compared with the children of disease control group and normal control group,in acute phase the plasma levels fo TNF-αand IL-6 in children with NPPE were significantly higher ( P<0.01 ) .The indicators of NPPE group significantly decreased after 48 hours therapy( P<0.01 ) .Conclusion NPPE is manifested by rapid onset of respiratory distress after relief of the airway obstruction.The symptoms resolve rapidly if early support of breath and limiting the fluid input volume are applied properly.The inflammatory response is one of the possible mechanisms of NPPE.

Clinical analysis of 9 patients with acute laryngitis and negative pressure pulmonary edema / 中华实用儿科临床杂志

Objective To investigate the clinical characteristics and treatment of negative pressure pulmonary edema (NPPE) with acute laryngitis in children,and to monitor the change of inflammatory factors.Methods The data of 9 cases with NPPE and acute laryngitis in Pediatric Intensive Care Unit of Xuzhou Children's Hospital from August 2010 to March 2015 were analyzed.Ten children of acute laryngitis without NPPE in our hospital were selected as the control group.The changes of the TNF-α and IL-6 between the 2 groups were compared before and after treatment.Results (1) All the 9 children in NPPE group were associated with third degree laryngeal obstruction.The onset of NPPE in 8 cases varied from 8 minutes to half an hour following relief of obstruction,and 1 child with NPPE occurred 2hours after relief of obstruction.Four of the 9 children had pink frothy pulmonary secretions but the other 5 children did not.NPPE chest radiograph showed diffuse interstitial and alveolar infiltrates.All these patients received these therapeutic measures including mechanical ventilation,retaining high positive end expiratory pressure (PEEP) (5-8 cmH2O,1 cmH2O =0.098 kPa),glucocorticoids,limiting the fluid input volume to 60-80 mL/(kg · d).Three of the 9 cases were treated with diuretics.The disappearance of rales on chest auscultation varied from 6 hours to 30 hours.Duration of mechanical ventilation was less than 48 hours,and all the children were cured.(2) The levels of TNF-α and IL-6 in NPPE group were significantly higher than those in the control group before treatment [(369.16 ± 48.19) ng/L vs(281.77 ± 45.59) ng/L,(30.39 ± 9.60) ng/L vs (20.43 ± 4.80) ng/L,P ＜ 0.05].After 48-hour treatment,the levels of TNF-α and IL-6 in both groups significantly decreased compared with before treatment (all P ＜ 0.01);and the levels of TNF-α and IL-6 in NPPE group were (281.10 ±47.45) ng/L and (20.04 ±5.87) ng/L,respectively,which were also significantly higher than those in the control group(P ＜ 0.05).Conclusions NPPE is manifested by rapid onset of respiratory distress rapidly after relief of the airway obstruction.Imaging suggested edema change.The prognosis will be good if early support of breath and limiting the fluid input volume are applied properly.The inflammatory response is one of the possible mechanisms of NPPE.

Post extubation negative pressure pulmonary edema due to posterior mediastinal cyst in an infant.

A 3‑month‑old male child underwent uneventful inguinal herniotomy under general anesthesia. After extubation, airway obstruction followed by pulmonary edema appeared for which the baby was reintubated and ventilated. The baby made a complete recovery and extubated after about 2 h. A post‑operative computed tomography scan revealed a posterior mediastinal cystic mass abutting the tracheal bifurcation. Presumably, extrinsic compression by the mass on the tracheal bifurcation led to the development of negative pressure pulmonary edema.

Negative pressure pulmonary edema / 国际儿科学杂志

Negative pressure pulmonary edema is a common pediatric disease,but also often to be ignored,which occurs from the upper airway obstruction caused by the change in the absolute value of negative intrathoracic pressure increase,resulting in a corresponding respiratory physiology,hemodynamic changes,common causes include laryngitis,whooping cough,foreign body,such as obstructive sleep apnea.Therefore,it is important to know the common causes of negative pressure pulmonary edema and to treat the patients in time.

Negative Pressure Pulmonary Edema Associated with Anterior Cervical Spine Surgery

We report a very rare case of negative pressure pulmonary edema (NPPE) that occurred immediately after anterior cervical discectomy and fusion (ACDF). The patient was a 25-year-old man who sustained a facet fracture-dislocation of C5 during a traffic accident. After ACDF, he developed NPPE and needed mechanical ventilation. Fortunately, he recovered fully within 24 hours. NPPE is a rare postoperative complication that may occur after cervical spine surgery. The aims of this report are to present information regarding the diagnosis and emergent treatment of NPPE, and to review the previous literature regarding this serious complication.

Stress-induced cardiomyopathy after negative pressure pulmonary edema during emergence from anesthesia: A case report / 대한마취과학회지

Stress-induced cardiomyopathy (SICM) presenting as an acute myocardial dysfunction is characterized by transient left ventricular wall motion abnormality, which has been known to be associated with excessive catecholamine production caused due to various types of stress. Sympathetic hyperactivity is common during the perioperative period, and reports of SICM occurring during this period have actually increased. We present a case of SICM following negative pressure pulmonary edema due to upper airway obstruction during emergence from anesthesia. Excessive catecholamine release in response to respiratory difficulty could have been the underlying inciting factor.

Post-extubation negative pressure pulmonary edema complicating laparoscopic appendectomy: A report of two cases

We report two cases of post-extubation negative pressure pulmonary edema in otherwise healthy patients. The patients underwent laparoscopic appendectomy under general anesthesia and developed negative pressure pulmonary edema immediately after extubation. All cases fully resolved within 24 hours with supplementary oxygen. The literature suggests that post-extubation pulmonary edema occurs more frequently than is generally thought, with a frequency of 0.05-0.1% in all anesthesia, and is often unrecognized or misdiagnosed. Most cases occur in the early post-operative period, and this is potentially life-threatening condition. Therefore, anesthesiologist and surgeon are well placed to witness, investigate and manage this condition.

Edema pulmonar por pressão negativa após extubação traqueal: relato de caso / Negative pressure pulmonary edema after tracheal extubation: case report

JUSTIFICATIVA E OBJETIVOS: O edema pulmonar por pressão negativa após obstrução de via aérea é atualmente uma entidade bem descrita, porém pouco diagnosticada e com poucos casos relatados. O objetivo deste artigo foi relatar um caso de edema pulmonar por pressão negativa (EPPN) após extubação traqueal com sucesso terapêutico, após uso de ventilação mecânica não-invasiva com pressão positiva. RELATO DO CASO: Paciente do sexo feminino, 22 anos, foi submetida à colecistectomia aberta. Os exames pré-operatórios encontravam-se sem alterações. Imediatamente após extubação a paciente apresentou dispnéia súbita e crepitações pulmonares. Foi iniciado tratamento para edema agudo de pulmão com oxigenoterapia sob máscara de Venturi, elevação do tórax e diurético. A paciente foi encaminhada a UTI devido a falha no tratamento. Ao chegar a UTI foi iniciada ventilação mecânica não-invasiva (VMNI) com pressão de suporte (15 cmH2O) e pressão expiratória final positiva (5 cmH2O) com resolução dos sintomas. A paciente foi mantida em observação por mais 24 horas depois do evento com boas condições e recebeu alta para o quarto sem sintomas. CONCLUSÕES: O EPPN é uma entidade de difícil diagnóstico e deverá ser observada sempre que os pacientes evoluem com sinais e sintomas de insuficiência respiratória pós-extubação. Esta paciente se beneficiou de VMNI, mas caso haja falha terapêutica, a intubação traqueal e o suporte ventilatório mecânico invasivo deverão ser instituídos para melhor oxigenação dos pacientes.

BACKGROUND AND OBJECTIVES: Negative pressure pulmonary edema after acute upper airway obstruction is a well-described event, thought infrequently diagnosed and reported. This report aimed at presenting a case of postextubation negative pressure pulmonary edema refractory to use of diuretics and with successful therapeutic after using positive pressure noninvasive mechanic ventilation. CASE REPORT: A 22-year-old-woman underwent an operation to opened colecistectomy. The preoperative exams were abnormality us. Immediately after the extubation the patient presented with dyspnea and lungs stertors. The treatment for the acute pulmonary edema started with oxygen therapy under Venturi mask, lifting up chest and diuretic. The patient was transferred to Intensive Care Unit due to the lack of success with the treatment. A noninvasive ventilation (NIV) was started with support pressure of 15 cmH2O and PEEP of 5 cmH2O with resolution of symptoms. The patient was maintained under observation for 24 hours after the event with good conditions and received discharge to room without symptoms. CONCLUSIONS: Negative pressure pulmonary edema (NPPE) is a difficult diagnosed event and it must be always considered when patient develop with symptoms and signals of respiratory insufficiency postextubation. In our case was possible to treat with positive pressure non-invasive mechanical ventilation, but in case of the NIV failure the tracheal intubation and the invasive mechanical ventilatory support be initiated to improve the oxygen levels of the patient.

Postobstructive pulmonary edema after laparoscopic surgery / 대한산부인과학회지

Negative pressure pulmonary edema (also known as postobstructive pulmonary edema) is a medical emergency that usually arises from attempted ventilations against an acutely obstructed upper airway, such as occurs during laryngospasm. Often this occurs in the perioperative period when general anesthesia is used. It is most important to the clinician because it must be promptly recognized and appropriately managed. Since hypoxia is the chief problem associated with this complication, adequate oxygen saturation remains the primary goal of treatment. We report a case of a 42-year-old female patient who was submitted to laparoscopic tubal reversal under general anesthesia and developed negative pressure pulmonary edema after an acute airway obstruction.

Postextubation Airway Obstruction and Negative-pressure Pulmonary Edema Due to a Laryngeal Cyst: A case report / 대한마취과학회지

Laryngeal cysts, including epiglottic cysts, are rare lesions which are clinically asymptomatic in many cases. Rarely laryngeal cysts cause unexpected airway management difficultties perioperatively. We report up on a case of laryngeal cyst that caused postextubation airway obstruction and negative-pressure pulmonary edema. A 25-year-old man was admitted for brain surgery with neurofibromatosis. He did not have any specific airway problem preoperatively, and anesthesia was done uneventfully. But when he was extubated after surgery, he revealed symptoms of upper airway obstruction in the recovery room. We reintubated him easily, and then we found a laryngeal cyst. Though negative-pressure pulmonary edema occurred after reintubation, he responded to conservative treatment and was discharged without specific problems. We present a review of postextubation airway obstruction and negative-pressure pulmonary edema due to a laryngeal cyst.