Clinical Features of Patients with Diffuse Alveolar Hemorrhage due to Negative-Pressure Pulmonary Edema

Negative-Pressure Pulmonary Edema Induced by Flexible Bronchoscopy: A Case Report

Negative-pressure pulmonary edema (NPPE) arises from excessive inspiratory effort due to upper airway obstruction, often associated with postoperative laryngospasm and upper airway infections like epiglottitis. We present a case of NPPE during bronchoscopy. A 45-year-old female patient, who was undergoing bronchoscopy for interstitial pneumonia evaluation, was examined using a tracheal tube with a 7.5 mm internal diameter and a bronchoscope with a 5.9 mm external diameter. The patient's respiratory condition gradually worsened after intubation. We continued with the examination, supplying approximately 5 L/min of oxygen through the intubation tube. We performed an alveolar lavage, and the recovered fluid gradually turned pale and bloody. After the examination, the patient continued to expectorate pink and frothy sputum and prolonged respiratory failure. Chest radiography revealed new extensive bilateral infiltrates. We ruled out cardiogenic causes through clinical examination, electrocardiogram (ECG), and transthoracic echocardiography. As a result, we suspected that temporary upper airway obstruction during bronchoscopy led to NPPE. Applying continuous positive airway pressure (CPAP) quickly improved the pulmonary edema. The risk of NPPE during bronchoscopy needs to be acknowledged, especially when using larger bronchoscopes and smaller tracheal tubes.

Negative pressure pulmonary edema after laparoscopic cholecystectomy: A case report and literature review

RATIONALE

Negative pressure pulmonary edema (NPPE) is an acute onset of non-cardiogenic interstitial pulmonary edema, commonly seen among surgical patients after extubation from general aneasthesia. It is mainly caused by rapid inspiration with acute upper airway obstruction resulting in significant negative thoracic pressure.

PATIENT CONCERNS

A 24-year-old female patient who underwent laparoscopic cholecystectomy under general anesthesia and developed NPPE postoperatively.

DIAGNOSES

Her main clinical manifestation was coughing up pink foamy sputum; postoperative CT showed increased texture in both lungs and bilateral ground glass opacities.

INTERVENTIONS

Diuretics and steroids were used, and symptomatic supportive treatments such as oxygen were given.

OUTCOMES

After treatment, on the fourth post-operative day, her symptoms were relieved and her vital signs were stable enough for her to be discharged.

LESSONS

Although this is a rare and severe complication, the prognosis of NPPE is good when it is managed with proper diagnosis and treatment.

Unexpected Diffuse Alveolar Hemorrhage After Bronchoscopy

CASE PRESENTATION

A 71-year-old woman sought treatment for a nonproductive cough. The patient had experienced no episodes of hemoptysis or shortness of breath. Her illness history included lumbago and dry mouth. The patient did not smoke and had no significant family medical history or medication use. She had no allergies to any food or drugs. Blood test results, including a CBC count, biochemical examination, and coagulation, were unremarkable. Autoantibody screening revealed positive antinuclear antibody findings with a titer of speckled and nucleolar, and anti-Ro/SSA antibodies were elevated at 240 U/mL (normal range, < 7.0 U/mL). Chest CT scan imaging showed a slight infiltrative shadow of the bilateral lower lobes. Because the patient was suspected to have interstitial pneumonia resulting from Sjögren disease, we decided to perform fiber optic bronchoscopy with BAL for evaluation of interstitial lung disease.

Negative pressure pulmonary edema (Review)

Negative pressure pulmonary edema (NPPE) is a complication resulting from acute or chronic upper airway obstruction, often posing challenges in recognition and diagnosis for clinicians. If left untreated, NPPE can lead to hypoxemia, heart failure and even shock. Furthermore, the drug treatment of NPPE remains a subject of controversy. The primary pathophysiological mechanism of NPPE involves the need for high inspiratory pressure to counteract upper airway obstruction, subsequently causing a progressive rise in negative pressure within the pleural cavity. Consequently, this results in increased pulmonary microvascular pressure, leading to the infiltration of pulmonary capillary fluid into the alveoli. NPPE exhibits numerous risk factors and causes, with laryngospasm following anesthesia and extubation being the most prevalent. The diagnosis of NPPE often presents challenges due to confusion with conditions such as gastroesophageal reflux or cardiogenic pulmonary edema, given the similarity in initial factors triggering both diseases. Upper airway patency, positive pressure non-invasive ventilation, supplemental oxygen and re-intubation mechanical ventilation are the foundation of the treatment of NPPE. The present review aims to discuss the etiology, clinical presentation, pathophysiology and management of NPPE.

„Negativdruck-Lungenödem“ und „alveoläre Hämorrhagie“ als Komplikationen einer oberen Atemwegsobstruktion

Negativdruck-Lungenödem und alveoläre Hämorrhagie sind lebensbedrohliche Komplikationen infolge einer akuten oberen Atemwegsobstruktion. Durch die Obstruktion im Larynx-/Pharynbereich kommt es zu hohen negativen Intrapleuraldrucken, die sich, durch unterschiedliche Faktoren bedingt, auf die Integrität der alveolo-kapillären Membran auswirken. In der Übersichtsarbeit werden klinische Symptome, Ätiologie, die Pathophysiologie sowie die therapeutischen Optionen beschrieben. Ziel ist es, den Kliniker mit den Krankheitsbildern und den Komplikationen vertraut zu machen.

Negative-pressure pulmonary Hemorrhaging Due to Severe Obstructive Sleep Apnea

A 24-year-old man with a history of bloody sputum for 6 months was referred to our hospital with suspected alveolar hemorrhaging due to vasculitis. Chest computed tomography showed ground-glass opacities in both lungs, and an examination of his bronchoalveolar lavage fluid showed alveolar hemorrhaging. However, no evidence of vasculitis was found, and subsequent polysomnographic testing confirmed that he had severe obstructive sleep apnea (OSA). Since the alveolar hemorrhaging improved after the initiation of continuous positive airway pressure treatment, the diagnosis was negative-pressure alveolar hemorrhaging due to severe OSA.

Diffuse Alveolar Hemorrhage Associated with Dilated Cardiomyopathy and Sleep Apnea Syndrome

We herein report a case of diffuse alveolar hemorrhage (DAH) associated with dilated cardiomyopathy (DCM) and sleep apnea syndrome (SAS) in a 47-year-old man. The patient exhibited recurring dyspnea and bloody sputum. Chest radiography showed bilateral diffuse infiltrative opacities without pleural effusion. A bronchoscopic analysis of bronchoalveolar lavage fluid revealed hemosiderin-laden macrophages. Based on these findings, he was diagnosed with DAH. Laboratory and pathological findings ruled out the possibility of collagen diseases and vasculitis. Overnight polysomnography revealed concomitant severe obstructive SAS. Treatment with continuous positive-pressure ventilation and pharmacological therapy for DCM prevented recurrence of DAH.

Radiologically and clinically diagnosed acute pulmonary oedema in critically ill patients: prevalence, patient characteristics, treatments and outcomes

Background: Acute pulmonary oedema is a life-threatening syndrome diagnosed based on radiological and clinical findings. However, to our knowledge, no studies have investigated this syndrome in critically ill patients. Objective: To describe the prevalence of radiologically and clinically diagnosed pulmonary oedema (RCDPO) in critically ill patients, characteristics of diagnosed patients, and treatments and outcomes in this patient population. Methods: We conducted a retrospective study using natural language processing to identify all radiological reports of pulmonary oedema among patients who had been admitted to single tertiary intensive care unit (ICU) over a 1-year period (January 2015 to January 2016). We reviewed clinical data, discharge diagnosis, treatment and outcomes for such patients, and used multivariable logistic regression analysis to identify the association of RCDPO with various outcomes. Results: Out of 2001 ICU patients, we identified 238 patients (11.9%) with RCDPO. Patients with RCDPO were more acutely ill, had more chronic liver disease and had more chronic renal failure than critically ill patients who did not have RCDPO. They were typically admitted with acute cardiovascular disease; were more likely to receive invasive mechanical ventilation and continuous renal replacement therapy; had longer duration of ICU and hospital stay; were more likely to die in hospital; and, if discharged alive, were more likely to be admitted to a chronic care facility. In total, 46 RCDPO patients (19.3%) died in hospital. On multivariable analysis, only age and continuous renal replacement therapy were independently associated with mortality. In contrast, invasive mechanical ventilation was associated with a 2.5 times greater odds of radiological resolution. Conclusion: RCDPO affected about one in eight ICU patients. Such patients were sicker and had more comorbidities. The presence of RCDPO was independently associated with higher risk of death. Invasive mechanical ventilation was the only intervention independently associated with greater odds of radiological resolution.

Unilateral pulmonary hemorrhage caused by negative pressure pulmonary edema: A case report

BACKGROUND

Unilateral pulmonary hemorrhage is typically reported in young and healthy men with upper respiratory tract obstruction during anesthesia in special situations. Negative pressure in the lungs is created, resulting in negative pressure pulmonary edema (NPPE).

CASE SUMMARY

A 78-year-old male patient diagnosed with spinal stenosis was admitted to receive a unilateral laminectomy with bilateral decompression. The patient had been diagnosed with hypertension four years earlier and asthma more than 70 years earlier. We experienced a unilateral alveolar hemorrhage associated with NPPE that occurred in a longstanding asthma patient who bit the intubated endotracheal tube for a short period during posture change at the end of surgery. Because diffuse alveolar hemorrhage accompanied by NPPE was caused in this case by airway obstruction in an older patient with asthma without known risk factors, anesthesiologists should be careful not to induce airway irritation during anesthesia awakening in asthma patients.

CONCLUSION

Because diffuse alveolar hemorrhage accompanied by NPPE can occur, anesthesiologists should take care not to induce airway irritation.

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.

Near-fatal negative pressure pulmonary oedema successfully treated with venovenous extracorporeal membrane oxygenation performed in the hybrid emergency room

We report a rare case of negative pressure pulmonary oedema (NPPE), a life-threatening complication of tracheal intubation. A 41-year-old obese man was admitted to a previous hospital for neck surgery. After extubation, he developed respiratory distress followed by haemoptysis and desaturation. The patient was reintubated and brought to our hospital where we introduced venovenous extracorporeal membrane oxygenation (ECMO) to prevent cardiac arrest, which is an unusual clinical course for NPPE. He returned to his routine without any sequelae. This is the first case report of NPPE successfully resolved with venovenous ECMO in the hybrid emergency room (hybrid ER), which is a resuscitation room equipped with interventional radiology features and a sliding CT scanner. Since the hybrid ER serves as a single move for patients where all necessary procedures are performed, it has the potential to lower the incidence of cannulation complications, beyond the delay in ECMO initiation.

Negative pressure pulmonary edema related with severe sleep apnea syndrome: A case report

Negative pressure pulmonary edema (NPPE) caused by airway obstruction was often life-threatening. Major cause of NPPE in adult patients was reported as post-operative laryngospasm. Therefore, NPPE was recognized widely among surgeons and anesthesiologist, but physicians also could face NPPE case in several clinical situation. NPPE in this case was caused by sleep apnea syndrome (SAS) as relatively rare cause. A 65-year-old female presented to emergency department due to disturbance of consciousness during sleep. This patient had desaturation requiring oxygen administration. Computed tomography showed pulmonary edema in bilateral lung fields. Comprehensive examination had no evident organic airway obstruction, and echocardiography showed normal cardiac function. This patient had been diagnosed with severe SAS with the apnea hypopnea index of 32 times/h. Therefore, we thought that the NPPE could be caused by severe SAS in this case. Continuous positive airway pressure therapy could improve this patient's symptoms promptly, and this patient could discharge without a complication. We should consider SAS as a cause of NPPE when examining NPPE patients especially with onset during sleep.

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

Negative 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.

Negative pressure pulmonary edema-related diffuse alveolar hemorrhage associated with Sevoflurane and cigarette smoking

Negative-pressure pulmonary edema (NPPE)-related diffuse alveolar hemorrhage (DAH) is an underdiagnosed clinical entity seen with alveolar capillary damage. The pathophysiology of type I NPPE is generation of a negative pleural pressure against an upper airway obstruction. We suspect this process was facilitated by preexisting alveolar damage with smoking and administration of the irritating and coagulopathic inhaled anesthetic sevoflurane. We present a case of a healthy 31-year-old man who developed postoperative hemoptysis, diffuse ground-glass opacity and infiltrates on computed tomography (CT) of the chest, anemia, and hypoxic respiratory failure. A diagnosis of DAH was made and a serologic workup for systemic disorders including vasculitis and connective tissue diseases was negative. The patient rapidly improved with supportive care and had complete resolution of his bilateral infiltrates on repeat chest x-ray two weeks later. Our literature review identified three cases of DAH in the setting of sevoflurane administration. Our case illustrates the importance of including NPPE-related DAH on the differential of post-operative hemoptysis, especially in association with sevoflurane administration and a history of cigarette smoking.

Negative pressure pulmonary edema after general anesthesia: A case report and literature review

RATIONALE

Negative pressure pulmonary edema (NPPE) is a dangerous clinical complication and potentially life-threatening emergency without prompt diagnosis and intervention during recovery period after anesthetic extubation.

PATIENT CONCERNS

A 25-year-old woman has undergone endoscopic thyroidectomy. After extubation, the patient developed acute respiratory distress with high airway resistance accompanied with wheezing, oxyhemoglobin saturation (SpO2) decreased to 70%. With positive pressure mask ventilation, her condition was stable, SpO2 99%. However, the patient developed pink frothy sputum with diffuse bilateral rales 30 min later after transported to surgical intensive care unit (SICU).

DIAGNOSES

Negative pressure pulmonary edema.

INTERVENTIONS

The patient was undergone assisted ventilation with continuous positive airway pressure (CPAP) and furosemide 20 mg was given intravenously.

OUTCOMES

Postoperative day (POD) 2 her condition became stable, computed tomography (CT) scan indicated the pulmonary edema disappeared. The patient was discharged 6 days later. No abnormalities were observed during following 4 weeks.

LESSONS

Although usually the onset of NPPE is rapid, with individual differences NPPE is still challenging. Increased vigilance in monitoring, diagnosis, and treatment are essential to prevent aggravation and further complication.

Diffuse alveolar hemorrhage following sugammadex and remifentanil administration: A case report

RATIONALE

Diffuse alveolar hemorrhage (DAH) is a rare life-threatening condition that accompanies general anesthesia. Negative-pressure pulmonary edema (NPPE) is a rare cause of DAH.

PATIENT CONCERNS

A 25-year-old male patient developed hemoptysis following remifentanil administration by bolus injection with sugammadex at the emergence from general anesthesia.

DIAGNOSIS

Chest x-ray and computed tomography showed DAH.

INTERVENTIONS

Conservative care was provided with 4L of oxygen via nasal prong, 20 mg of Lasix and 2500 mg of tranexamic acid.

OUTCOMES

The patient was discharged uneventfully.

LESSONS

Muscle rigidity by remifentanil and the dissociated reversal of neuromuscular blockade by sugammadex was suspected as the cause of NPPE-related DAH. Therefore, the possibility NPPE-related DAH should be considered when using a bolus of remifentanil and sugammadex during emergence from general anesthesia.

Negative pressure pulmonary edema postextubation following medial nerve repair with sural graft surgery in a young patient: A case report

RATIONALE

Negative pressure pulmonary edema (NPPE) is a serious well-described pulmonary complication. It occurs after an intense inspiratory effort against an obstructed or closed upper airway and generates a large negative airway pressure, leading to severe pulmonary edema (transvascular fluid filtration and interstitial/alveolar edema) and hypoxemia. We present a case of NPPE following general anesthesia in a patient who underwent median nerve neurorrhaphy with graft from lower left limb (sural nerve) due to sharp injury.

PATIENT CONCERNS

A 39-year-old Hispanic male was admitted to the Hospital Universitario de San José and scheduled to undergo a median nerve neurorrhaphy under general anesthesia. Preoperative vital signs, physical examination, and laboratory assessments were unremarkable. At the end of surgery, anesthetic agents were ceased after patient responded to commands and maintained eye contact. However, immediately after extubation, anesthesia care providers observed marked respiratory distress and rapid development of hypoxia.

DIAGNOSES

After extubation, patient presented multiple episodes of hemoptysis, tachypnea (25 per minute), blood oxygen saturation (SpO2) of 82% and abundant bilateral pulmonary rales. A baseline chest x-ray revealed symmetric parenchymal opacities with ground-glass attenuation and bilateral multilobar consolidations patterns. The diagnosis of NPPE was established and supportive treatment was initiated.

INTERVENTIONS

The patient received noninvasive mechanical ventilation with a PEEP at 10 cmH2O, intravenous furosemide (20 mg.) every 12 hours, and fluids restriction. Patient remained in PACU for continuing monitoring and laboratory/imaging follow-up testing until next morning.

OUTCOMES

On postoperative day 1, patient responded satisfactorily to supportive treatment and transferred to the general care floor; oxygen supplementation was discontinued 12 hours after extubation time. On postoperative day 3, after the evaluation of a chest x-ray, patient was discharged to home in stable conditions LESSON:: The occurrence of NPPE in the perioperative setting could be successfully managed with supportive regimens, effective clinical team coordination, and awareness of the importance of its rapid diagnosis.

Acute Postobstructive Pulmonary Edema Following Laryngospasm in Elderly Patients: A Case Report

Only a few cases regarding postobstructive pulmonary edema following laryngospasm in older patients aged more than 60 years have been reported; however, acute pulmonary edema or pulmonary hemorrhage would be more deadly to elderly patients who have cerebrovascular disease than young healthy adults. After review of the literature, we report an unusual case of a 67-year-old man with ischemic cerebrovascular disease, who underwent carotid angioplasty and stenting and experienced severe pulmonary edema and hemorrhage secondary to laryngospasm after general anesthesia with laryngeal mask airway. The patient required positive-pressure ventilation, supportive treatment, and active cerebroprotection in the intensive care setting for 3 days before the edema resolved, and subsequently made a complete recovery without new onset of neurologic sequelae. The possible pathophysiological mechanisms, precaution, and preventative strategy of postobstructive pulmonary edema in older patients are discussed.

Hémorragies intra-alvéolaires

L’hémorragie intra-alvéolaire (HIA), maladie rare, est une urgence thérapeutique, car elle peut conduire rapidement vers une insuffisance respiratoire aiguë asphyxiante avec décès. La triade, hémoptysie–anémie–infiltrat radiologique, suggère le diagnostic d’HIA, mais elle peut manquer dans deux tiers des cas, y compris chez des patients en détresse respiratoire. La tomodensitométrie thoracique peut aider dans les formes atypiques. Le diagnostic d’HIA repose sur la réalisation d’un lavage bronchoalvéolaire. Les étiologies en sont très nombreuses. Il importera de séparer, en urgence, les HIA d’origine non immune, avec un dépistage de celles d’origine septique qui doivent bénéficier d’une enquête microbiologique ciblée et cardiovasculaire avec la réalisation d’une échographie cardiaque, des HIA immunes (les vascularites liées aux anticorps anticytoplasme des polynucléaires neutrophiles, les connectivites et le syndrome de Goodpasture), avec la recherche d’autoanticorps et la réalisation de biopsies au niveau des organes facilement accessibles. La biopsie pulmonaire doit rester exceptionnelle. En cas d’HIA immune inaugurale, un traitement par stéroïdes et cyclophosphamide peut être débuté. Les indications du rituximab commencent à être mieux établies. Le bénéfice des échanges plasmatiques est débattu. En cas de réapparition d’infiltrats pulmonaires, chez un patient suivi pour une HIA immune, on s’efforcera d’écarter une infection dans un premier temps.