Post-Extubation Pulmonary Edema Following Anesthesia Induced by Upper Airway Obstruction: Are Certain Patients at Increased Risk?

doi:10.1378/chest.90.6.802

Chest

Volume 90, Issue 6, December 1986, Pages 802-805

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Pulmonary edema due to upper airway obstruction can be observed in a variety of clinical situations. The predominant mechanism is increased negative intrathoracic pressure, although hypoxia and cardiac and neurologic factors may contribute. Laryngospasm associated with intubation and general anesthesia is a common cause of pulmonary edema in children. However, only seven cases of pulmonary edema presumably due to laryngospasm have been reported in adolescents and adults. Five of the seven had other risk factors for upper airway obstruction, and in four, the diagnosis of “laryngospasm” could be explained by other factors. Patients with underlying risk factors for upper airway obstruction, such as a forme fruste of sleep apnea or nasopharyngeal abnormalities, appear to be at increased risk for the development of pulmonary edema in the setting of intubation and anesthesia. This form of pulmonary edema usually resolves rapidly without the need for aggressive therapy or invasive monitoring.

Section snippets

CASE REPORT

A 48-year-old white man weighing 288 pounds developed hemoptysis of one teaspoonful per day. He was admitted to the ENT service for triple endoscopy (nasopharyngoscopy, esophagoscopy, and tracheoscopy) due to a presumed ENT source of bleeding.

He had hypertension controlled on clonidine and a thiazide diuretic. His wife noted nocturnal apnea and upper airway obstructive symptoms, although the patient did not have symptoms of daytime hypersomnolence. Admission chest radiograph was normal.

DISCUSSION

It is interesting to note that many of the adults described with pulmonary edema secondary to UAO from presumed laryngospasm have had underlying risk factors for UAO on the basis of soft tissue obstruction (Table 1). The patient reported by Jackson et al¹⁰ was obese with a short, thick neck, and the vocal cords were never visualized nor the trachea intubated. The obstruction occurred after initiation of anesthesia, and the patient could not be ventilated with bag and mask; breath sounds were

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Citation Excerpt :
Negative pressure PPE (NPPE) develops after deep inspiratory effort against a closed glottis [31]. Marked and prolonged increases in negative pressure gradients result in a shift in fluid from capillaries to lung parenchyma and eventual damage to the capillary walls [31]. Postictal laryngospasm has been reported [32] and NPPE may thus be relevant in some cases of SUDEP.
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El edema pulmonar por presión negativa (NPPE) es una complicación anestésica por obstrucción aguda de la vía aérea superior, su principal causa es el laringoespasmo. La fisiopatología radica en una marcada presión negativa intrapleural durante una inspiración contra glotis cerrada, la cual desencadena una presión excesiva en la microvasculatura pulmonar. El diagnóstico puede ser difícil, su reconocimiento ayuda a minimizar la morbimortalidad. En este artículo se presenta un caso de NPPE por laringoespasmo postextubación.
Negative pressure pulmonary oedema (NPPO) is an anaesthetic complication due to acute obstruction of the upper airway, whose main cause is laryngospasm. The pathophysiology involves a strong negative intrapleural pressure during inspiration against a closed glottis, which triggers excessive pressure in the pulmonary microvasculature. Although its diagnosis can be difficult, its recognition helps to minimise morbidity and mortality. This article presents a case of NPPO due to postextubation laryngospasm.
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Citation Excerpt :
This finding logically follows that young, healthy patients are physiologically capable of generating large enough negative intrathoracic pressure to induce some of the pathophysiologic changes associated with POPE. Additional risk factors for developing POPE in the perioperative setting include anatomically difficult intubation, nasal, oral, or pharyngeal surgical site of pathology, obesity with obstructive apnea, short neck, and acromegaly [16-18]. Individual case reports have also associated POPE using endotracheal tube adaptors during thoracotomy [19], narcotic use, vocal cord paralysis [20], endotracheal tube obstruction [21], premature extubation [22], marked coronal narrowing of the intrathoracic trachea (“saber sheath” trachea) [23], and during induction in children who developed hiccups [24].
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.
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O edema agudo do pulmão pós-extubação traqueal é um acontecimento raro (≈ 0,1%)¹. A etiologia é multifactorial, sendo a obstrução da via aérea superior o factor desencadeante principal. O esforço inspiratório contra a glote encerrada causa pressões intratorácicas muito negativas, que se transmitem ao interstício pul-monar, condicionando uma transudação de fluidos a partir dos vasos capilares pulmonares¹⁻⁵. Relatamos um caso de edema agudo do pulmão pós-extubação num doente de quinze anos, operado no serviço de urgência por amputação traumática da perna esquer-da. Revemos a fisiopatologia, o padrão radiológico, potenciais factores de risco e medidas preventivas des-ta complicação respiratória pós-anestésica.
Rev Port Pneumol 2009; XV (3): 537-541
Negative pressure pulmonary oedema is an uncommon complication of traqueal extubation (≈ 0,1%) mostly caused by acute upper airway obstruction. Upper airway obstruction from glottis closure leads to marked inspiratory effort, which generates negative intrathoracic pressure transmitting to pulmonary interstitium, and inducing fluid transudation from pulmonary capillary bed^1 −5. We report a case of post-extubation pulmonary oedema in a fifteen years old patient, submitted to surgery following traumatic amputation of his left leg. We review the pathophysiology, radiological findings, potential risk factors and preventive measures of this post-anaesthetic respiratory complication.
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Postextubation pulmonary edema: A case series and review
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We report a series of patients with postextubation pulmonary edema who had no obvious risk factors for the development of this syndrome.
Patients identified by the pulmonary consultation service at an academic medical center were reviewed.
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.
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.

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: Manuscript received May 12; revision accepted July 1.

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Chest

Clinical InvestigationsPost-Extubation Pulmonary Edema Following Anesthesia Induced by Upper Airway Obstruction: Are Certain Patients at Increased Risk?

Section snippets

CASE REPORT

DISCUSSION

Chest

Chest

Lancet

Pulmonary edema secondary to laryngospasm in children

Anesthesiology

Pulmonary edema associated with croup and epiglottitis

Pediatrics

Pulmonary edema following relief of upper airway obstruction

Ann Otol Rhinol Laryngol

Epiglottitis and pulmonary edema in children

Canadian Anaesthesia Society Journal

Mechanical forces producing pulmonary edema in acute asthma

N Engl J Med

Pulmonary edema as a complication of acute airway obstruction

JAMA

Near-drowning

Crit Care Med

Clinical Investigations
Post-Extubation Pulmonary Edema Following Anesthesia Induced by Upper Airway Obstruction: Are Certain Patients at Increased Risk?