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

## TL;DR

A patient developed pulmonary edema during bronchoscopy due to upper airway obstruction, highlighting the risk of this procedure when using mismatched equipment.

## Contribution

This case report highlights NPPE as a rare complication of bronchoscopy and emphasizes the importance of equipment size compatibility.

## Key findings

- A 45-year-old female developed NPPE during bronchoscopy with a mismatched bronchoscope and tracheal tube.
- Pulmonary edema resolved quickly with CPAP after ruling out cardiogenic causes.
- The case underscores the risk of NPPE when using larger bronchoscopes with smaller tracheal tubes.

## Abstract

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.