Abstract
BackgroundPost-extubation negative pressure pulmonary edema (NPPE) is an uncommon but important anesthesia-related emergency presenting with acute respiratory distress and hypoxemia after removal of airway devices. This study investigated the incidence and associated risk factors for post-extubation NPPE during emergence.MethodsThis retrospective, matched case-control study was conducted by reviewing the post-anesthesia records in Tzu Chi General Hospital, Taiwan. Patients reported of having acute hypoxemia (SpO2 < 92%) shortly after the removal of the endotracheal tube or supraglottic airway, associating with radiographic evidence of pulmonary edema and/or pink frothy sputum, were identified as definite NPPE cases. The potential risk factors were compared with the matched controls, who were randomly selected from the same database.ResultsA total of 85,561 patients received general anesthesia with airway instrumentation during the 8.5-year study period. A total of 16 patients were identified as definite cases of NPPE. Compared with the matched controls (n = 131), males, active smokers, emergency operation, endotracheal intubation, use of desflurane, and prolonged operation time carried significantly higher risks of developing NPPE (P < 0.05). Multivariate logistic regression analysis illustrated that active smoking (AOR 7.66, 95% CI 1.67–35.3; P = 0.009) and endotracheal intubation (AOR 10.87, 95% CI 1.23–100; P = 0.03) were the two most significant independent variables of post-extubation NPPE.ConclusionWe present the first clinical comparative study demonstrating that the overall incidence of NPPE immediately after extubation in the operating room is 0.019%. Our results highlight that active smokers and patients receiving endotracheal intubation general anesthesia are associated with significantly higher risks of developing NPPE following extubation in the operating room.
Highlights
Post-extubation negative pressure pulmonary edema (NPPE) is an uncommon but important anesthesiarelated emergency presenting with acute respiratory distress and hypoxemia after removal of airway devices
There were a total of 117,762 patients who received anesthesia management during the 8.5-year period in our hospital, and 85,545 of these surgical patients were anesthetized with an endotracheal tube (ETGA) or laryngeal mask (LMA) (Fig. 1)
The foremost important clinical message addressed in this study is that post-extubation NPPE is a relatively rare complication in the operating room with an overall incidence of 0.019% (≈ 19 cases in 100,000 general anesthesia with airway instrumentation), but it results in increased extraneous medical cost, as 56% of patients who developed unexpected NPPE after extubation were admitted to intensive care unit (ICU) for postoperative care, and it engendered to a case of mortality in this study
Summary
Post-extubation negative pressure pulmonary edema (NPPE) is an uncommon but important anesthesiarelated emergency presenting with acute respiratory distress and hypoxemia after removal of airway devices. This study investigated the incidence and associated risk factors for post-extubation NPPE during emergence. NPPE is usually a benign condition typically resulting in full recovery within 12–48 h (Krodel et al 2010). It can be a true post-anesthesia emergency that requires immediate tracheal re-intubation, and up to 50% of these patients are subjected to prolonged mechanical ventilatory support due to acute respiratory failure (Krodel et al 2010; McConkey 2000). We performed a retrospective, matched case-control study to analyze the overall incidence and the associated risk factors of post-extubation NPPE during the emergence period of anesthesia from the database of post-anesthesia records in our hospital
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