Negative Pressure Pulmonary Edema Research Articles

Veno-Venous Extracorporeal Membrane Oxygenation - Rapid Recovery for Post-Surgical Negative Pressure Pulmonary Edema

Introduction Postoperative pulmonary edema can be cardiogenic, non-cardiogenic or a combination of both. A major cause of noncardiogenic edema is negative pressure pulmonary edema (NPPE) due to inspiration against a closed glottis. Within minutes, patients can develop dyspnea and pink tinged frothy sputum. Risk factors include a short neck, obstructive sleep apnea, and previous ENT surgeries. There have also been a few case reports that demonstrate NPPE after the use of sevoflurane. Below we present a case of a young female who developed post-surgical NPPE which was managed with short-term veno-venous extracorporeal membrane oxygenation (V-V ECMO). Case Report A 30-year-old female with minimal past medical history was airlifted to the cardiovascular intensive care unit four hours after a condyloma removal under sevoflurane anesthesia with a laryngeal mask airway. The patient developed post-operative hypoxia and hemoptysis requiring intubation. A computerized tomography (CT) scan of the chest with contrast revealed ground-glass opacities concerning for diffuse alveolar hemorrhage (DAH). Upon arrival, a bronchoscopy with sequential lavages revealed persistently sanguineous fluid which pointed away from active alveolar hemorrhage. The ECMO team was consulted due to concerns for acute lung injury. Given the preserved cardiac function, the patient was placed on V-V ECMO for two days with rapid recovery of lung function. The patient was maintained on ventilator support for two additional days before being discharged on the fifth day. Summary The mainstay of treatment for NPPE is supportive care. Most patients require prolonged monitoring in the postanesthesia care unit and usually recover within a few hours with supplemental oxygen and continuous positive end-expiratory pressure. Occasionally, patients will need to be intubated. In this case, the post-procedural CT scan showed no signs of cardiogenic pulmonary edema, but rather DAH. Given ventilation difficulties with adequate cardiac function, the patient was an appropriate candidate for V-V ECMO. The DAH could possibly be due to sevoflurane but was more likely a consequence of NPPE. Regardless of the cause, the use of V-V ECMO is highly effective in allowing patients to rapidly recover respiratory function without long-term complications.

Negative-pressure-related diffuse alveolar hemorrhage after monitored anesthesia care for vertebroplasty: a case report

BackgroundDiffuse alveolar hemorrhage (DAH) is a rare, life-threatening condition that can present as a spectrum of nonspecific symptoms, ranging from cough, dyspnea, and hemoptysis to severe hypoxemic respiratory failure. Perioperative DAH is frequently caused by negative pressure pulmonary edema resulting from acute airway obstruction, such as laryngospasm, although hemorrhage itself is rare.Case presentationThis case report describes an unexpected hemoptysis following monitored anesthesia care for vertebroplasty. A 68-year-old Asian woman, with a compression fracture of the third lumbar vertebra was admitted for vertebroplasty. There were no noticeable events during the procedure. After the procedure, the patient was transferred to the postanesthesia care unit (PACU), at which sudden hemoptysis occurred. The suspected airway obstruction may have developed during transfer or immediate arrive in PACU. In postoperative chest x-ray, newly formed perihilar consolidation observed in both lung fields. The patients was transferred to a tertiary medical institution for further evaluation. She diagnosed with DAH for hemoptysis, new pulmonary infiltrates on chest x-ray and anemia. The patient received supportive care and discharged without further events.ConclusionsShort duration of airway obstruction may cause DAH, it should be considered in the differential diagnosis of postoperative hemoptysis of unknown etiology.

Child Case with Negative Pressure Pulmonary Edema After Upper Airway Obstruction

Child Case with Negative Pressure Pulmonary Edema After Upper Airway Obstruction

NEGATIVE PRESSURE PULMONARY EDEMA FOLLOWING OUTPATIENT SHOULDER ARTHROSCOPY WITH AN INTERSCALENE BLOCK

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Negative Pressure Pulmonary Edema (NPPE) complicated by acute hypoxemic respiratory failure (AHRF) following extubation in patients undergoing elective shoulder surgery is uncommon. We report a case of unilateral NPPE complicated by AHRF requiring emergent reintubation in a patient who received an interscalene block. CASE PRESENTATION: A 50-year-old obese male with history of obstructive sleep apnea (OSA) and unprovoked DVT presented for elective left shoulder arthroscopy. Patient was a difficult intubation, but surgery was otherwise uncomplicated. Following extubation, patient developed hypoxemia requiring noninvasive ventilation (NIV) with transition to bilevel NIV. On post-op evaluation, patient was tachycardic and hypoxemic with bilateral crackles on lung auscultation. A portable chest x-ray showed bilateral alveolar opacities, right greater than left, consistent with pulmonary edema. Given history of unprovoked DVT, a CT pulmonary angiogram (CTPA) was obtained, and patient was transiently placed on a non-rebreather mask for transport. After CTPA, patient developed red frothy sputum, altered sensorium, and worsening hypoxemia. Returning to the ICU, patient had an oxygen saturation of 80%. Rapid sequence intubation was successfully performed on first pass. During intubation patient had a brief episode of PEA arrest requiring CPR and one dose of epinephrine. Mechanical ventilation (MV) with high PEEP and supportive care led to clinical improvement and extubation 36 hours after reintubation. DISCUSSION: NPPE is a post-anesthesia complication occurring in 0.1% of cases. Patient had risk factors for NPPE: male gender, OSA, known difficult airway, and obesity. Patient’s pharyngeal obstruction due to OSA likely caused NPPE. NPPE can be difficult to differentiate from pneumonitis and other causes of pulmonary edema. The anesthesiologist did not observe perioperative aspiration, and patient had a net even fluid balance making cardiogenic pulmonary edema unlikely. In patients with post-op hypoxemia and concern for NPPE, a chest radiograph is the test of choice. NIV and supportive care are the main treatments for NPPE, but some cases require reintubation and MV. Patient’s chest CT showed alveolar opacities much greater on the right than left along with left hemidiaphragm elevation. Interscalene block on the left likely caused left phrenic paresis. The supine position required for CT imaging likely further exacerbated patient’s respiratory failure requiring emergent airway management. CONCLUSIONS: NPPE is a rare life-threatening post-anesthesia complication. Interscalene block can lead to phrenic nerve paresis with resultant diaphragmatic dysfunction. NPPE in the setting of unilateral phrenic nerve paresis has seldom been described. Most patients require NIV; however, some patients need reintubation and a brief period of MV with supportive care. Reference #1: Bhattacharya M, Kallet RH, Ware LB, Matthay MA. Negative-Pressure Pulmonary Edema. CHEST. 2016 Oct; 150 (4): 927-933 Reference #2: Betts A, Eggan JR. Unilateral Pulmonary Edema with Interscalene Block. Anesthesiology. 1998 Apr; 88 1113-4 Reference #3: Mulkey Z, Yarbrough S, Guerra D, Roongsritong C, Nugent K, Phy MP. Postextubation pulmonary edema: a case series and review. Respiratory Medicine. 2008;102 (11):1659 DISCLOSURES: No relevant relationships by Max Barnes, source=Web Response No relevant relationships by Matthew Koroscil, source=Web Response No relevant relationships by Paul Pikman, source=Web Response

IT’S ALL IN THE STORY: A MISLEADING CHEST CT

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: An abnormal chest CT is a common reason for pulmonary consultation. There is a wide differential and a thorough history is important in helping to hone in on a diagnosis. Here, we present a case where the floridly abnormal chest CT was misleading. CASE PRESENTATION: The pulmonary team was consulted for an abnormal chest CT with request for bronchoscopy. A 32 yo woman without major past medical history presented to the ED short of breath - she described running for the bus and suddenly not being able to breathe. Labs on arrival significant for lactic and respiratory acidosis, suggesting near respiratory arrest. She improved rapidly with nebulizers, rest, and oxygen, and quickly weaned back to room air; her labs also improved rapidly. Her CXR showed patchy opacities so a chest CT was obtained showing diffuse ground glass opacities (Figure 1). She denied a wide range of exposures. Part of the thyroid obtained on the chest CT looked enlarged; she reported having been told several months ago that her thyroid was enlarged, and on exam it was noticeably large. A CT of the neck showed enlarged thyroid causing compression of the upper airway (Figure 2). We suspected the cause of her abnormal CT to be negative pressure pulmonary edema in the setting of likely upper airway obstruction caused by her enlarged thyroid. The initial ENT consult team did not feel this was related, however a secondary consult with endocrine surgery agreed with immediate resection of the thyroid. The patient was monitored in the MICU with heliox at the bedside, and underwent the resection without complication; she was surprisingly able to be intubated easily. She recovered fully and is now doing well; repeat CXR showed improvement. DISCUSSION: Negative pressure pulmonary edema (NPPE) is most commonly reported in the post-operative period from laryngospasm causing deep inspiration against a closed upper airway.1 This intense negative pressure pulls fluid into the alveolar space. Treatment involves addressing the underlying issue, whether it be laryngospasm or upper airway obstruction, with which the edema should rapidly resolve. Other cases have reported large thyroid masses causing similar presentations.2 Heliox can be used in cases of respiratory distress from narrowed airways, as its properties provide much less turbulent flow.3 It has been used to decrease intubation rates in children with croup, patients with subglottic stenosis, and even in severe asthma exacerbations. CONCLUSIONS: NPPE can cause an extremely abnormal chest CT, though the history and rapid improvement will help rule out other causes and rapidly narrow the differential. Heliox can be used to help improve oxygenation and ventilation in the setting of a narrowed upper airway. Patients improve with treatment of underlying obstruction or laryngopasm. Reference #1: Bhattacharya, M., Kallet, R. H., Ware, L. B. & Matthay, M. A. Negative-Pressure Pulmonary Edema. Chest 150, 927–933 (2016). Reference #2: Goh, K. J., Koh, M. S. & Tay, C. K. The Aftermath of Relieving an Upper Airway Obstruction. A Case of Postobstructive Pulmonary Edema. Am. J. Respir. Crit. Care Med. 198, e106–e108 (2018). Reference #3: Hashemian, S. M. & Fallahian, F. The use of heliox in critical care. Int. J. Crit. Illn. Inj. Sci. 4, 138–142 (2014). DISCLOSURES: No relevant relationships by Catherine Gao, source=Web Response No relevant relationships by Lisa Wolfe, source=Web Response

CT Findings in Negative Pressure Pulmonary Edema.

Negative pressure pulmonary edema (NPPE) is a rare, potentially life-threatening, and yet diagnostically challenging perioperative complication. Most cases of NPPE occur in the context of anesthetic procedures, mainly caused by upper airway obstruction, and are diagnosed during the recovery period. We present a case of fulminant NPPE in a patient during general anesthesia which illustrates the eye-catching CT findings that can occur in NPPE and eventually support diagnosis. With regard to the current pandemic, we include a discussion of the typical imaging patterns of COVID-19 as a radiological differential diagnosis of NPPE. A 42-year old male patient presented with sudden respiratory insufficiency during arthroscopic knee lavage and subsequently required highly invasive ventilation therapy and catecholamine administration. Postoperative CT imaging of the thorax exhibited extensive, centrally accentuated consolidations with surrounding ground-glass opacity in all lung lobes, suggestive of pulmonary edema. In view of the clinical course and the imaging findings, a negative pressure pulmonary edema (NPPE) was diagnosed.

Negative Pressure Pulmonary Edema Occurring While Snorkeling

Our story begins on a tropical island, in which infectious disease physician Dr. John Guilfoose spent his vacation to partake in underwater photography and snorkeling. Dr. Guilfoose describes the story that began when he saw a large sea turtle as he was snorkeling in the bay. Puerto Rico has two major islands, Culebra, which is known for wealth-- very touristy. And then there’s Vieques, which I think was originally a bombing strip for American military. But it turns out it has an incredibly redeemed component from a tourist perspective of bioluminescent bays. So, I just got there, checked into the hotel, and wanted to go snorkeling. Did not bring any of my own stuff. And so, I went out and just rented some cheapy snorkel. Do not know if this is pertinent, but it could be. I hyper- hydrated right before going snorkeling. So, I drank like five big glasses of water. It might have something to do with the expansion of positive volume right before I went into the water.

Isolated Oropharyngeal Muscle Spasm in a Young Child post Extubation: A Case Report

Agitation during emergence from anaesthesia is a documented phenomenon reported in children especially during immediate postoperative period; also Voluntary breath holding1and laryngospasm. This can lead to complications like postoperative distress, excessive crying, and anxiety. Here we report a case of postoperative respiratory distress in an 8 years old child of cerebral palsy developing severe oropharyngial spasm in the immediate postoperative period. Patient had no preoperative predisposing factors or intaraoperative events that could cause bronchospasm, laryngospasm, inadequate neuromuscular reversal or voluntary holding in the immediate postoperative period. Timely recognition and management of the condition prevented catastrophic complications like severe desaturation, hypoxic injury, negative pressure pulmonary edema or cardiac arrest.

Systematic Review of Negative Pressure Pulmonary Edema in Otolaryngology Procedures.

Negative pressure pulmonary edema (NPPE) is a rare perioperative complication with a potentially fatal outcome. The aim of this study was to perform a systematic review of NPPE in adult otolaryngology procedures with the goal of identifying risk factors, clinical presentation, diagnosis, management and outcomes. Systematic review performed using PubMed, Scopus, Web of Science, and Cochrane databases. Sixty-nine studies including data from 87 individual patients were included in this review. Fifty-six (68%) patients were male and the average patient age was 37 years old. Type 1 NPPE occurred in 63 (72%) cases, while type 2 NPPE accounted for 20 (23%) cases. The most common procedures leading to NPPE were septoplasty, rhinoplasty or sinus surgery (n = 22, 25%), directly laryngoscopy or bronchoscopy (n = 13, 15%), and tracheostomy or cricothyroidotomy (n = 11, 13%). The most employed treatment options included diuretics (n = 55, 63%) and mechanical ventilation (n = 54, 62%). Seventy-eight (90%) patients made a full recovery with an average time to NPPE resolution of 33 hours and an average length of hospitalization of 5.6 days. Five (6%) patients had a long-term morbidity and four (5%) patients died, with age and ICU stay increasing risk for death and long-term morbidity (OR 1.044 and 7.42, respectively, P < .05). Septoplasty, rhinoplasty and sinus surgery account for the majority of NPPE cases in adult otolaryngology procedures. Young, healthy patients are the most commonly involved with a slight male predominance. The vast majority of patients recover fully, however there is a significant risk for morbidity and mortality.

Negative Pressure Pulmonary Edema: A Case Report

Negative pressure pulmonary edema is an uncommon complication of the extubation of the endotracheal tube. An increase in intrathoracic pressure and negative pressure of the lung caused by acute laryngeal spasm results from acute upper respiratory obstruction causing life-threatening pulmonary edema by alveolar-capillary damage is called negative pressure pulmonary edema. We here describe 28-years old female case the preoperative diagnosis of pelvic inflammatory disease undergoing exploratory laporoscopy caused negative pressure pulmonary edema while extubation. With the immediate treatment, the patient was discharged without any abnormalities.

Negative Pressure Pulmonary Edema After Orthognathic Surgery

Negatif basincli pulmoner odem ekstubasyon sonrasi ust solunum yolu obstruksiyonu olan hastalarda gelisebilmektedir. Bu calismanin amaci ortognatik cerrahi sonrasi n egatif basincli pulmoner odem gelisen bir vakanin takdimi ve bu konu ile ilgili calismalari derlemektir . Yirmi yedi yasindaki erkek hastaya cift cene osteotomisi uygulandi. Postanestezi bakim unitesinde hastada belirgin solunum depresyonu ve arterial oksijen desaturasyonu gelisti. Hasta yeniden entube edildi ve yogun bakim unitesine alindi . Ikinci ve 3. gunlerde alinan akciger grafilerinde vaskuler konjesyonda azalma oldugu goruldu. T edavi surecinde C-reaktif protein, lokosit ve notrofil sayisi, arteryal oksijen ve karbondioksit parsiyel basinclarinda iyilesme goruldu. Negatif basincli pulmoner odem ortognatik cerrahi sonrasi gorulebilen, yasami tehdit eden bir komplikasyondur; erken tani ve uygun tedavi protokolu ile bu komplikasyonun basarili bir sekilde yonetimi mumkundur.

Negative-Pressure Pulmonary Edema After Septoplasty

Negative-pressure pulmonary edema is a rare but life-threatening complication of septoplasty seen in the early-postoperative period. The main cause is laryngospasm; often with hypoxia and hemoptysis. In our case, a 36-year-old septoplasty recipient developed symptoms of hypotension, tachycardia and low oxygen saturation 3 hours after extubation. The patient was diagnosed with negative-pressure pulmonary edema. Treatment was applied with noninvasive positive pressure ventilation and diuretics. It should be noted that negative pressure pulmonary edema may vary in terms of presentation and may not be accompanied by laryngospasm.

Negative-pressure pulmonary edema(NPPE): patient biting endotracheal tube

Negative-pressure pulmonary edema(NPPE): patient biting endotracheal tube

Comparison of Sugammadex versus Neostigmine Costs and Respiratory Complications in Patients with Obstructive Sleep Apnoea.

To compare sugammadex and neostigmine regarding the efficacy in reversing rocuronium-induced neuromuscular block, the incidence of post-operative respiratory complications and costs in patients undergoing surgery for the treatment of obstructive sleep apnoea (OSA). After obtaining ethical approval and patient consent, 74 patients in ASA physical status I or II were randomised into two groups to receive 2-mg kg(-1) sugammadex (Group S) or 0.04-mg kg(-1) neostigmine+0.5-mg atropine (Group N). Groups were compared regarding time to TOF (train-of-four) 0.9, operating room time, post-anaesthesia care unit (PACU) stay, post-operative respiratory complications, costs related to neuromuscular block reversal, anaesthesia care and complication treatment. Patient demographics, anaesthesia, surgical data and total rocuronium doses were similar between groups. Time to TOF 0.9 was shorter for group S [Group N: 8 (5-18) min; Group S: 2 (1.5-6) min (p<0.001)]. Operating room time [Group S: 72.4±14.3 min; Group N: 96.6±22.8 min (p<0.001)] and PACU stay [Group S: 22.9±10.1 dk; Group N: 36.3±12.6 dk (p<0.001)] were also shorter in Group S. After extubation, desaturation was observed in 12 (32.4%) patients in group N and in 4 (8%) patients in group S (p=0.048). In group N, three patients were reintubated; there were eight (21.6%) unplanned intensive care unit (ICU) admissions. There was one unplanned ICU admission in group S. Negative pressure pulmonary oedema was observed in one patient in group N. The results regarding costs were as follows. The reversal cost was higher in the sugammadex group (vial cost 98.14 TL) than that in the neostigmine group (ampoule cost 0.27 TL; total 6147.88 TL vs. 3569.5 TL); however, complication treatment cost and total cost were lower in group S than those in group N (199.5 TL vs. 3944.6 TL) (staff anaesthesia doctor cost was 0.392 TL per min and the cost of nurse anaesthetist was 0.244 TL per min). This study confirmed the efficacy of sugammadex over neostigmine for the reversal of rocuronium-induced neuromuscular block. Sugammadex decreases the incidence of post-operative respiratory complications and related costs in patients with OSA.

Delayed presentation of negative pressure pulmonary oedema

Negative pressure pulmonary oedema (NPPO) is a life-threatening complication occurring due to large negative intrathoracic pressures created by inspiration against a closed glottis. Timely diagnosis and management is important to prevent any fatal outcome. Although it presents acutely most of the time, its presentation may rarely be delayed. We present a case of a 21-year-old female weighing 40 kg who developed NPPO 1.5 h after warding in the post-anaesthesia care unit. Despite the delayed presentation, she was diagnosed in a timely manner and managed successfully. This case emphasises the need for extended monitoring of all patients with any respiratory difficulty in the perioperative period for delayed development of NPPO.

Negative-pressure pulmonary edema following percutaneous nephrolithotomy

Negative pressure pulmonary edema (NPPE) or post-extubation pulmonary edema is an infrequent complication that usually occurs immediately or within several minutes after tracheal extubation in healthy, muscular adolescents and young adults. NPPE begins when upper airway obstruction occurs which causes an increase in negative intrathoracic pressure to pull fluid from the pulmonary capillary bed and into the alveoli which leads to ventilation and perfusion difficulties. Presenting here a case of bilateral renal stone posted for percutaneous nephrolithotomy under general anesthesia in prone position who desaturated immediately in the post-operative period after extubation. It also suggests the importance, prevention, diagnosis and treatment of NPPE.

Negative pressure pulmonary edema following laryngospasm.

Negative pressure pulmonary edema following laryngospasm.

Negative Pressure Pulmonary Edema and APRV Mode in Invasive Mechanical Ventilation: A Case Report

Negative Pressure Pulmonary Edema and APRV Mode in Invasive Mechanical Ventilation: A Case Report

A case of a dog with negative pressure pulmonary edema caused by brachycephalic airway syndrome

A case of a dog with negative pressure pulmonary edema caused by brachycephalic airway syndrome

Negative Pressure Pulmonary Edema as a Cause of Diffuse Alveolar Hemorrhage in the Newborn

AbstractNegative pressure pulmonary edema (NPPE) is a rare entity that can become life threatening. Its development in neonates is very rare, and its presentation as alveolar hemorrhage is uncommon. We report a case of a newborn 23 days old, previously healthy, who presented an episode of choking during breastfeeding. This progressed to acute respiratory failure due to diffuse alveolar hemorrhage. A few hours after admission, the newborn developed refractory hypoxemia, requiring high-frequency oscillatory ventilation and nitric oxide therapy for 24 hours. NPPE was postulated as a diagnosis of exclusion. The newborn recovered completely. NPPE should always be considered in a case with recent obstruction of the upper airway, even in unusual age groups. Sometimes it can manifest as alveolar hemorrhage.