Conservative Management of Negative Pressure Pulmonary Edema: A Case Report

TL;DR

A case report shows that mild negative pressure pulmonary edema can be successfully treated with conservative methods like oxygen and positioning, avoiding the need for invasive ventilation.

Contribution

This case highlights the effectiveness of conservative management in mild NPPE, offering a non-invasive alternative to reintubation.

Findings

Conservative treatment with oxygen, positioning, and furosemide resolved mild NPPE within hours.

Early recognition and non-invasive care prevented the need for mechanical ventilation.

NPPE can present on a spectrum from mild to severe, requiring tailored treatment approaches.

Abstract

Negative pressure pulmonary edema (NPPE) represents a less frequently encountered, albeit critical, etiology of non-cardiogenic pulmonary edema, manifesting subsequent to acute upper airway obstruction. It is most often seen in young, healthy adults with strong inspiratory effort, usually triggered by post-extubation laryngospasm. Although the presentation can be dramatic, most patients recover completely when the condition is recognized and managed early. A young adult man underwent a laparoscopic appendectomy under general anesthesia. During emergence, he developed acute laryngospasm while biting down on the endotracheal tube, resulting in strong inspiratory effort against an obstructed upper airway. Shortly after extubation, he produced copious pink, frothy sputum and experienced hypoxemia consistent with NPPE. He was managed conservatively with supplemental oxygen, gentle suctioning, lateral and mild Trendelenburg positioning, and a single dose of intravenous furosemide. His oxygenation improved within hours, and he was discharged home later on, the same day without further complications. Most reports of NPPE describe more severe cases that require reintubation and mechanical ventilation, often with positive end-expiratory pressure or advanced ventilatory modes. In contrast, this case demonstrates that mild NPPE can resolve rapidly with conservative, non-invasive treatment when identified early. The patient's ability to maintain spontaneous ventilation and stable hemodynamics allowed for a measured approach focused on relieving obstruction, improving oxygenation, and promoting alveolar fluid clearance. Early lateral positioning and diuresis likely helped mobilize pulmonary fluid and enhance recovery. This case underscores that NPPE presents on a spectrum, from mild, self-limited episodes to severe respiratory failure, and that treatment should be tailored accordingly. Early recognition and prompt conservative management can lead to rapid recovery in mild NPPE, preventing unnecessary reintubation and the risks associated with mechanical ventilation. Awareness of its variable presentation is essential for safe anesthetic practice.

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