Postoperative pulmonary edema in young, athletic adults

Bedside ultrasound in post-anaesthetic care unit for the diagnosis of post-extubation negative pressure pulmonary oedema: A paediatric case

BACKGROUND

Post-extubation negative pressure pulmonary oedema is a rare, potentially life-threatening complication associated with general anaesthesia. Chest radiography is used as a diagnostic tool, but it implies a non-negligible radiation exposure, a very important consideration, especially for the paediatric population. However, lung ultrasound can overcome this problem and can be used to detect postoperative pulmonary complications.

CASE REPORT

A 16-year-old male was scheduled for tympanoplasty. General anaesthesia was conducted, and after extubation, the patient developed a laryngospasm. On arrival at the post-anaesthetic care unit, the patient started to cough, a pink frothy sputum and hypoxemia were noticed, and auscultation revealed crepitations. A bedside lung ultrasound showed more than three B-lines per intercostal window, suggesting an alveolar-interstitial syndrome.

DISCUSSION

With this case report, we would like to raise awareness to this clinical entity and demonstrate bedside ultrasound has an important role in the diagnostic and therapeutic assessment during the perioperative period.

Negative Pressure Pulmonary Edema Related to Laryngospasm and Upper Airway Obstruction in a Patient With Treacher Collins Syndrome

Laryngospasm is an uncommon complication of anesthesia in adults but more common in pediatric anesthesia, which could present similarly to supraglottic upper airway obstruction. The management of such airway complications is even more difficult in patients with difficult mask ventilation and intubation. Our case illustrated the management of laryngospasm and negative pressure pulmonary edema in a patient with Treacher Collins syndrome. A literature search revealed few previous similar reports. We demonstrated an algorithm to differentiate between the true laryngospasm from the supraglottic upper airway obstruction, the management of laryngospasm in patients with difficult airways, and the recognition and management of negative pressure pulmonary edema as a complication of laryngospasm.

Extraordinary Delayed-Onset Negative Pressure Pulmonary Hemorrhage Resulting in Cardiac Arrest after General Anesthesia for Vocal Cord Polypectomy

Negative pressure pulmonary edema and hemorrhage are uncommon but potentially life-threatening complications associated with general anesthesia. Postoperative negative pressure pulmonary edema usually occurs immediately after surgery, and delayed-onset cases occurring more than 1 hour after surgery have rarely been reported. A 37-year-old woman with bronchial asthma underwent vocal cord polypectomy under general anesthesia in another hospital and experienced cardiac arrest due to a negative pressure pulmonary hemorrhage occurring 3 hours and 30 minutes after surgery. She was successfully treated with venoarterial extracorporeal membrane oxygenation and completely recovered without any complications. Extraordinary delayed-onset negative pressure pulmonary hemorrhage occurring more than three hours after surgery has rarely been reported. This case may indicate the need for more careful observation of patients following surgery.

Preoperative Evaluation: Estimation of Pulmonary Risk Including Obstructive Sleep Apnea Impact

One in 4 deaths occurring within a week of surgery are related to pulmonary complications, making it the second most common serious morbidity after cardiovascular events. The most significant predictors of the postoperative pulmonary complications (PPCs) are American Society of Anesthesiologists physical status, advanced age, dependent functional status, surgical site, and duration of surgery. The overall risk of PPCs can be predicted using scores that incorporate readily available clinical data.

Negative pressure pulmonary edema after percutaneous endoscopic interlaminar lumbar discectomy-a case report

BACKGROUND

Negative pressure pulmonary edema (NPPE) is a rare complication that is more prevalent in young patients. NPPE usually results from acute upper airway obstruction, which is most commonly caused by laryngospasm during extubation. NPPE is characterized by the sudden onset of coughing, hemoptysis, tachycardia, tachypnea, and hypoxia, and is dramatically improved with supportive care, which prevents severe sequelae. To our knowledge, there is no report of a patient developing NPPE after percutaneous endoscopic interlaminar lumbar discectomy.

CASE PRESENTATION

Herein, we report the case of a 22-year-old amateur basketball player with L5/S1 disc herniation who developed NPPE during extubation after general anesthesia for a minimally invasive spinal surgery (percutaneous endoscopic interlaminar lumbar discectomy). The NPPE was treated by maintaining the airway patency, applying positive-pressure ventilation, administering dexamethasone and antibiotics, and limiting the volume of fluid infused. The patient had an uneventful postoperative course, and was discharged to his home on postoperative day 3.

CONCLUSIONS

Although NPPE is an infrequent complication, especially in patients undergoing percutaneous endoscopic interlaminar lumbar discectomy, this case report highlights the importance of early diagnosis and prompt treatment of NPPE to prevent the development of potentially fatal complications.

[Negative pressure pulmonary edema following a cholecystectomy - A case report]

Negative pressure pulmonary edema (NPPE) or post-obstructive pulmonary edema (POPE) is a rare but a life threatening respiratory situation. The most frequent cause of NPPE is a post anesthetic laryngospasm. Edema is developed after relief of upper airway obstruction. Its incidence is 0.1 % of general anesthesia with tracheal intubation. We report this clinical case of a 28-year-old woman, who developed dyspnea followed by acute respiratory distress with unilateral pulmonary edema after extubation following general anesthesia for cholecystectomy under celioscopy. After elimination of any other cause, context, clinical and radiological characteristics, and the favorable evolution under oxygen and furosemide made it possible for us to link this acute respiratory distress to a NPPE whose pathophysiological causes and mechanisms are discussed.

Postobstructive pulmonary edema after biopsy of a nasopharyngeal mass

We describe a case of 17 year-old male with a nasopharyngeal rhabdomyosarcoma who developed postobstructive pulmonary edema (POPE) after removing the endotracheal tube following biopsy. He developed muffled voice, rhinorrhea, dysphagia, odynophagia, and difficulty breathing through nose and weight loss of 20 pounds in the preceding 2 months. A nasopharyngoscopy revealed a fleshy nasopharyngeal mass compressing the soft and hard palate. Head and neck MRI revealed a large mass in the nasopharynx extending into the bilateral choana and oropharynx. Biopsy of the mass was taken under general anesthesia with endotracheal intubation. Immediately after extubation he developed oxygen desaturation, which did not improve with bag mask ventilation with 100% of oxygen, but improved after a dose of succinylcholine. He was re-intubated and pink, frothy fluid was suctioned from the endotracheal tube. Chest radiograph (CXR) was suggestive of an acute pulmonary edema. He improved with mechanical ventilation and intravenous furosemide. His pulmonary edema resolved over the next 24 h. POPE is a rare but serious complication associated with upper airway obstruction. The pathophysiology of POPE involves hemodynamic changes occurring in the lung and the heart during forceful inspiration against a closed airway due to an acute or chronic airway obstruction. This case illustrates the importance of considering the development of POPE with general anesthesia, laryngospasm and removal of endotracheal tube to make prompt diagnosis and to initiate appropriate management.

Negative pressure pulmonary edema with laryngeal mask airway use: Recognition, pathophysiology and treatment modalities

Negative pressure pulmonary edema (NPPE) following the use of the laryngeal mask airway (LMA) is an uncommon and under-reported event. We present a case of a 58-year-old male, who developed NPPE following LMA use. After biting vigorously on his LMA, the patient developed stridor upon emergence, with concurrent appearance of blood-tinged, frothy sputum and pulmonary edema. He subsequently required three days of mechanical ventilation. After discontinuation of mechanical ventilation the patient continued to require additional pulmonary support using continuous positive airway pressure, with a full facemask, to correct the persistent hypoxemia. His roentgenographic findings demonstrated an accelerated improvement with judicious administration of intravenous furosemide.

Hemoptysis after orthopedic surgery in an adolescent boy

In children, post-obstructive pulmonary edema is a rare condition, caused by a sudden change in upper airway patency. It causes dyspnea, tachypnea, hypoxemia, and at times hemoptysis and respiratory insufficiency. It occurs as a complication in the immediate post-operative period. Pediatricians should be aware of this clinical entity.

Negative pressure pulmonary edema revisited: Pathophysiology and review of management

Negative pressure pulmonary edema (NPPE) is a dangerous and potentially fatal condition with a multifactorial pathogenesis. Frequently, NPPE is a manifestation of upper airway obstruction, the large negative intrathoracic pressure generated by forced inspiration against an obstructed airway is thought to be the principal mechanism involved. This negative pressure leads to an increase in pulmonary vascular volume and pulmonary capillary transmural pressure, creating a risk of disruption of the alveolar-capillary membrane. The early detection of the signs of this syndrome is vital to the treatment and to patient outcome. The purpose of this review is to highlight the available literature on NPPE, while probing the pathophysiological mechanisms relevant in both the development of this condition and that involved in its resolution.

Recurrent negative pressure pulmonary edema

An African-American man, aged 34 years, underwent an elective uncomplicated right wrist laceration repair while under general anesthesia. Following extubation, the patient developed hypoxemia, tachypnea, shortness of breath, pulmonary rales, frothy sputum, decreased oxygen saturation, and evidence of upper airway obstruction. Chest radiograph showed pulmonary edema. The patient was diagnosed with post-extubation pulmonary edema (aka. negative pressure pulmonary edema [NPPE]) and was treated with intravenous furosemide and oxygen therapy; he improved remarkably within a few hours. Once stabilized, the patient described a similar episode 10 years earlier following surgery for multiple gunshot wounds. Negative pressure pulmonary edema following tracheal extubation is an uncommon (0.1%) and life-threatening complication of patients undergoing endotracheal intubation and general anesthesia for surgical procedures. The common pattern in these cases is the occurrence of an episode of airway obstruction upon emergence from general anesthesia, usually caused by laryngospasm. Patients who are predisposed to airway obstruction may have an increased risk of airway complications upon extubation after general anesthesia. Prevention and early relief of upper airway obstruction should decrease incidence. Recurrent NPPE has not been previously described in the literature. Herein, we describe the first case of recurrent NPPE in the same patient following extubation.

Postobstructive pulmonary edema

Postobstructive pulmonary edema (POPE; also known as negative pressure pulmonary edema) is a potentially life-threatening complication in which pulmonary edema occurs shortly after the relief of an upper airway obstruction. The incidence of POPE has been reported to be as high as 1 in 1000 general anesthetic cases and commonly presents as acute respiratory distress that requires immediate intervention. This review examines the 2 subclasses of POPE and describes the etiologic factors, pathophysiology, clinical manifestations, diagnostic criteria, and treatment strategies associated with each. The aim of this review was to equip clinicians with the knowledge base necessary to identify patients at increased risk for POPE and to expeditiously diagnose and treat this potentially catastrophic complication.

Perioperative management of patients who have pulmonary disease

The identification of risk factors and optimization of respiratory status are crucial to the successful management of patients who have pulmonary disease and are undergoing a surgical procedure. This article explores the approach to pulmonary patients, from the preoperative assessment to the intraoperative and postoperative periods. The management of specific pulmonary disorders in the perioperative period is discussed.

Negative pressure pulmonary edema in the prone position: a case report

Acute airway obstruction can result in life - threatening pulmonary edema. It can develop rapidly, without warning, in otherwise healthy patients. Negative pressure pulmonary edema has been described after acute airway obstruction in situations when a patient is breathing against an obstructed airway such as croup, epiglottitis or laryngospasm. In the following case, we observed a rare occurrence of pulmonary edema in a female following sedation in the prone position.

Age specific differences in pediatric obstructive sleep apnea

BACKGROUND

Some have suggested that younger children have a more severe form of obstructive sleep apnea than older children and therefore are at a higher risk for respiratory compromise after tonsillectomy and adenoidectomy. However, at present there are few studies that have identified any significant correlation between age and severity of obstructive sleep apnea.

OBJECTIVE

To determine if age specific differences in obstructive sleep apnea are present in children.

DESIGN

Retrospective chart review.

SETTING

Tertiary care children's hospital.

PATIENTS

The records of children (1-18 years of age) with obstructive sleep apnea diagnosed by overnight polysomnography between January 1998 and January 2001 were reviewed. Children included in the study also had evidence of adenotonsillar hypertrophy and had no other co-existing medical problems.

MAIN OUTCOME MEASURES

Overnight polysomnography was performed in all children. Apnea-hypopnea index (AHI), baseline and lowest O(2) saturation, baseline and peak end tidal CO(2), and total number of obstructive apneas, hypopneas, central apneas and mixed apneas were measured during each polysomnogram. Children were subdivided into the following age groups: 1-2, 3-5, 6-11 and 12-18 years. Polysomnograms were classified into normal, mild, moderate and severe categories.

RESULTS

Three hundred and sixty-three children were studied; 45 children were ages 1-2 years, 159 children were ages 3-5 years, 137 children were 6-11 years and 22 children were 12-18 years. Although there appears to be a trend towards a greater mean number of obstructive apneas, hypopneas, central apneas, mixed apneas, a higher mean AHI, lower mean SaO(2) nadir, and a higher mean PETCO(2) in the younger age groups when compared to the older groups, a Student's t-test demonstrates that there is no statistical significance for most OSA parameters. An analysis of variance using the F-test reveals statistical significance (p<0.01) when children ages 1-2 were compared to those 3-5, 6-11 or 12-18 years of age for the variables AHI, mean number of central apneas, hypopneas and mixed apneas. When comparing patients in the various severity categories, children ages 1-2 years show a distinct distribution with a larger percentage in the moderate to severe categories. Chi square analysis reveals a significant difference between the frequency distribution of children in age group 1-2 years and that of the other age groups (p<0.01).

CONCLUSION

There is a predilection for children less than 3 years of age to have more severe obstructive sleep apnea as documented by polysomnography. Central apnea also appears to be more common in this age group. These findings may be explained by anatomic and physiologic differences related to age and support a period of observation following adenotonsillectomy in younger children.

Postextubation pulmonary edema: a case series and review

We report a series of patients with postextubation pulmonary edema who had no obvious risk factors for the development of this syndrome.

METHODS

Patients identified by the pulmonary consultation service at an academic medical center were reviewed.

RESULTS

Fourteen cases were collected and analyzed. The average age was 34.5 years; 12 patients were male. The average BMI was 25.5. None had documented previous lung disease. Most operations were scheduled as outpatient procedures, and the type of surgery ranged from an incision and drainage of a bite wound to an open reduction-internal fixation of the radius. None of the patients had upper airway surgery. The length of surgeries ranged from 27 to 335 min. Laryngospasm was the most commonly identified obstructing event postextubation. Treatment involved airway support when needed, supplemental oxygen, and diuretics.

CONCLUSIONS

It would appear that all patients, especially young men, are at risk for the development of this syndrome and that the pathogenesis remains uncertain in many cases.

A case of negative-pressure pulmonary edema after electroconvulsive therapy

Pulmonary edema after electroconvulsive therapy (ECT) is a rarely reported condition that can result in serious morbidity and even death if not promptly recognized and treated. We report the case of 21-year-old man with FG syndrome and schizophrenia who developed negative-pressure pulmonary edema after his 28th ECT. The patient developed acute hypoxemia requiring positive-pressure ventilation and was observed overnight in the intensive care unit. He recovered fully and received 43 subsequent ECT treatments without complication. This case illustrates the importance of taking steps to prevent airway obstruction as well as recognizing this rare but serious complication.

[Haemoptysis after anesthesia]

Postobstructive pulmonary oedema is a complication after extubation that occurs rarely . It can be associated with haemoptysis. We report two cases of haemoptysis occuring in ASA 1 otherwise healthy patients who underwent uncomplicated anaesthesia. Understanding of the mechanism and prompt treatment lead to rapid recovery of this dramatic complication.

Negative-pressure pulmonary edema after routine septorhinoplasty: discussion of pathophysiology, treatment, and prevention

OBJECTIVE

To provide rhinologic surgeons with an understanding of acute negative-pressure pulmonary edema (NPPE) and its treatment.

DESIGN

Case report and literature review of all published adult cases of NPPE. Patient factors, anesthetic variables, and outcomes are assessed.

RESULTS

A total of 146 cases in 45 case reports and series were compiled. There was approximately a 2:1 male-female patient ratio. The average age of the patients was 33 years. Fifty percent of patients had surgery on the upper aerodigestive tract, and 8% had intranasal surgery. No patients received laryngotracheal anesthesia, and 5 of the 146 received intravenous lidocaine prior to extubation. One patient had NPPE following laryngeal mask airway treatment, and 2 patients experienced this complication after conversion from monitored anesthesia care to general endotracheal anesthesia; 33.5% of patients were treated with continuous positive airway pressure alone, while 66.5% required intubation and mechanical ventilation. The average time to resolution was 11.75 hours. Three patients died.

CONCLUSIONS

It is known that surgical procedures involving the upper aerodigestive tract have a higher risk of NPPE than other procedures. Rapid diagnosis and treatment is necessary to achieve early resolution and avoid significant patient morbidity. A thorough understanding is integral to the practice of nasal and paranasal sinus surgery, especially with the rising use of outpatient and office-based surgical suites. Therefore, we present a review of pathophysiologic mechanisms, possible risk factors, treatment options, and potential steps that can be taken to minimize this potentially devastating complication of general anesthesia.

Negative pressure post-extubation pulmonary edema complicating appendectomy in a young patient: Case report

Negative-pressure pulmonary edema after endotracheal intubation is an uncommon and potentially serious complication of patients undergoing general anesthesia for different surgical procedures. We report a case of a healthy 20-year-old male patient with the diagnosis of acute appendicitis. The patient was submitted to appendectomy under general anesthesia and developed negative-pressure pulmonary edema immediately after extubation. The present paper reports this potentially serious complication illustrating the main radiological findings consistent with alveolar hemorrhage in this setting and the treatment performed.

Pulmonary oedema induced by strenuous swimming: a field study

The purpose of the study was to document the incidence and recurrence rate of pulmonary oedema induced by strenuous swimming (SIPO), and to study the changes in relevant physiological parameters. Thirty-five young men were repeatedly examined over a 2-month period after a swimming time trial in the open sea. A tentative diagnosis of SIPO was made when the swimmer reported shortness of breath accompanied by cough. Twenty-nine events of SIPO were diagnosed in 21 individuals (60% incidence). Oxygen saturation was significantly reduced in SIPO. Mean forced vital capacity (FVC) and FEV(1) were significantly lower in the severe SIPO group. Also, mean FVC and mid-expiratory flows (FEF(25-75%)) obtained 12 months earlier during screening for the programme were lower in individuals who later had SIPO. The ratios of post-swim FVC and FEV(1) values to the corresponding selection examination values were lower in the severe SIPO group. Thus volumes decreased in the SIPO group, besides being lower at the start. Shortness of breath and coughing following strenuous swimming were related to hypoxaemia and reduction in lung volumes, suggesting pulmonary oedema. SIPO was a common and often recurrent phenomenon. Lower initial lung volumes and flows might predict future susceptibility to SIPO.

Postobstructive pulmonary oedema--a case series and review

Six cases of post-extubation pulmonary oedema in otherwise healthy patients are reported. All were preceded by an episode of laryngospasm and followed a clinical course similar to that previously documented in cases of post-obstructive pulmonary oedema. Frank haemoptysis was a feature of five of the presentations. One patient was reintubated and ventilated, two were admitted to the intensive care unit for mask CPAP, one was managed with CPAP in the recovery ward and two with supplemental oxygen only. All cases resolved fully within 24 hours. Some evidence points to the syndrome being the result of airway bleeding rather than true pulmonary oedema. The literature suggests that it occurs more commonly than is generally thought, with a frequency of 0.05 to 0.1% of all anaesthetics, and is often unrecognised or misdiagnosed. Most cases occur in the early postoperative period, so anaesthetists are well placed to witness, investigate and manage this interesting condition.

Postlaryngospasm pulmonary edema in adults

Laryngospasm is a potential serious complication of intubation. Pulmonary edema can develop after laryngospasm and can affect any patient who has been intubated. Postlaryngospasm pulmonary edema is potentially life threatening and can result in reintubation, mechanical ventilation, admission to an intensive care unit, and a prolonged hospitalization for the patient. Perioperative nurses play a significant role in the prompt detection, diagnosis, and treatment of this syndrome.

Negative-pressure pulmonary edema in the otolaryngology patient

It is estimated that 11% of all patients requiring active intervention for acute upper airway obstruction develop negative-pressure pulmonary edema. This pathologic process typically has a benign and rapidly resolving clinical course with the prompt use of mechanical ventilation and positive end expiratory pressure. A review of the literature, however, has revealed a morbidity and mortality rate of 11% to 40% in reported series. During the years 1991 through 1993, six patients were identified in whom negative-pressure pulmonary edema developed after various otolaryngologic procedures. Five (84%) of the six patients had complete resolution of the pulmonary edema within 24 hours, and the sixth patient progressed to prolonged mechanical ventilation and eventual death. In an effort to further understand the pathophysiology of this disease, a cardiac evaluation was performed by use of echocardiography on all six patients. In three of the six patients, studies revealed an underlying cardiac anomaly not previously identified by history or physical examination. Findings included one case of hypertrophic cardiomyopathy and two cases of pulmonary and tricuspid valvular insufficiency. This 50% incidence of cardiac anomalies is striking, in contrast to the less than 1% incidence of these anomalies in the general adult population. To our knowledge, this is the first study to implicate an underlying cardiac cause for the generation of negative-pressure pulmonary edema. On the basis of this study, we recommend that echocardiography be a part of the routine evaluation of all patients who manifest negative-pressure pulmonary edema. (Otolaryngol Head Neck Surg 1997;117:62–6.)

Laryngospasm and noncardiogenic pulmonary edema

The incidence of laryngospasm in the PACU after extubation remains low despite the number of extubations that are performed annually. A study of general anesthesia patients conducted by Olsson and Hallen in 1977 & reported by Holmes et al (Am J Sports Med 19:365-371, 1991) showed the incidence of laryngospasm to be 8.7/1,000 patients. A literature review since 1977 presents a clinical picture of an emergent situation that may be anticipated by nursing staff (Hamlin et al: J Post Anesth Nurs 6:43-49, 1991). Noncardiogenic pulmonary edema (NCPE), also called negative-pressure pulmonary edema (NPPE) (De Franco M: Crit Care Nurse 9:20-22, 1993), and postextubation laryngospasm induced pulmonary edema (LIPE), can be a serious complication of laryngospasm. Its etiology and thus its treatment differs from other forms of noncardiogenic pulmonary edema, such as acute respiratory distress syndrome (ARDS). The PACU nurse must be aware that any patient has the potential for postextubation laryngospasm, and must be prepared to initiate appropriate treatment of noncardiogenic pulmonary edema.

Bronchoscopic findings in post-obstructive pulmonary oedema

PURPOSE

To present the first photographed bronchoscopic findings associated with negative pressure pulmonary oedema (NPPE).

CLINICAL FEATURES

A previously healthy patient underwent anterior C3-C4 disc removal and arthrodesis. Following tracheal extubation he developed acute respiratory distress manifested as stridor, tachypnoea, restlessness, and desaturation. Once the trachea was reintubated, he displayed the classic findings of pulmonary oedema. Bronchoscopy was performed to confirm tracheal tube position and to rule out tracheal injury secondary to surgical manipulation. Diffuse punctate haemorrhages were noted throughout the visualised tracheobronchial tree.

CONCLUSION

We believe that these haemorrhages represent disruption of the bronchial vasculature and may contribute to the clinical presentation of NPPE.

Postobstructive pulmonary edema induced by endotracheal tube occlusion

Pulmonary edema is a well-described complication of upper airway obstruction, most commonly caused in adults by postanesthetic laryngospasm. The mechanism initiating the formation of postobstructive pulmonary edema is believed to be the markedly negative intrapleural pressure generated by a forceful inspiratory effort against an obstructed extrathoracic airway. We herein describe a young, male patient who developed pulmonary edema postoperatively, upon emergence from anesthesia, after performing repeated, forceful inspiratory maneuvers directed against an endotracheal tube on which he had bitten down, thereby occluding it. To our knowledge, such an etiology of postobstructive pulmonary edema has not previously been described.