Negative pressure pulmonary edema (NPPE) or postobstruction pulmonary edema (POPE) is a clinical entity of great relevance in anesthesiology and intensive care. The presentation of NPPE can be immediate or delayed, which therefore necessitates immediate recognition and treatment by anyone directly involved in the perioperative care of a patient.

1. Case Presentation

2. Case study
• 30 year old male NKCM on list for primary eye
repair (Due to trauma)

3. Pre Op Assesment
Systmetic Review
CVS : No Hx of HTN ,SOB,Chest pain ,Palpitations
Chest: NVB + 0 No Hx of cough, asthama,COPD,T.B
CNS: GCS 15/15 No neurological focal deficiet
Liver:No Previous Hx of Hep B & C

4. Air way assesment
• MP :1
• No loose or artifical teeth
• Adequate neck movements
• Previous surgical Hx was insignificant

5. Work up
• CBC: HB 16,TLC:11000,PLT: 2lac
• CXR PA view

6. INDUCTION
• Intubated with propofol ( 100mg )
• Nalbufine( 10mg )
• Midazolam (2mg)
• Atracurium (10mg)
• Intra operative maintained with Isoflurane 1.2%
• A good analgesic and anti emetics given
• Intra operative patient was vitally stable

7. • At the time of extubation there is no increase in B.P
• Patient was smoothly extubated
• In recovery patient de-saturated 80% O2 on room air
• Intially saturation improved by giving high flow O2
• After 30 mins patient again desaturated

8. Post Operative Managment
• On chest examination B/L crepetation through out lung
field.
• Stop I/V Fluids
• Pass foleys catheter 16 FR immediately
• Inj Lasix 80mg I/V. Stat
• On nebulization with ventolin & atrovent
• After 2 hr urine output adequate ,B/L crepetation
decrease
• Patient retain in recovery whole night for observation.

9. • Patient shift back in ward after night

10. Negative preesure pulmonary edema (NPPE)
• Negative pressure pulmonary edema (NPPE) or
postobstruction pulmonary edema (POPE) is a clinical
entity of great relevance in anesthesiology and intensive
care. The presentation of NPPE can be immediate or
delayed, which therefore necessitates immediate
recognition and treatment by anyone directly involved in
the perioperative care of a patient.
• The incidence of NPPE has been reported to be 0.05%–
0.1% of all anesthetic practices; however, it is suggested
that it occurs more commonly than is generally
documented

11. Classifications
• This disorder is classified as Type I or Type II
• Type I NPPE develops immediately after onset of acute
airway obstruction
• Type I NPPE develops usually with upper airway acute
obstruction or after manipulation of the airway surgically,
some authors call it laryngeal spasm-induced pulmonary
edema
• Type II NPPE develops after the relief of chronic upper
airway obstruction.

12. Risk factors

13. Pathophysiology

14. Clinical presentation
• In clinical presentation, initial findings usually include decreased
oxygen saturation, with pink frothy sputum and chest radiograph
abnormalities.
• Manifestations of the acute airway obstruction include stridor,
suprasternal and supraclavicular retractions, urgent use of
accessory muscles of inspiration, and panic in the facial
expression.
• As NPPE develops, auscultation usually reveals crackles and
occasionally wheezes. Pulmonary edema causes both impaired
diffusion of oxygen and ventilation/perfusion mismatching, leading
to sudden and possibly severe hypoxemia.

15. • The typical chest radiograph will show diffuse interstitial
and alveolar infiltrates

16. Diagnosis

17. Management
• The first treatment priority is relief of the airway obstruction and correction of
hypoxemia. The next step is to address the pulmonary edema with a diuretic
unless the patient is hypovolemic.
• Effective airway management and immediate treatment with oxygen and
diuretics is sufficient in most cases of NPPE. Persistent airway obstruction
may necessitate an artificial airway, and acute respiratory failure would
require artificial ventilation with oxygen and appropriate levels of PEEP.
• If the airway obstruction is due to the patient biting down on the
endotracheal tube, a dose of succinylcholine (0.1–0.2 mg/kg) may be needed
to relax the jaw muscles, although controversial use of steroids in NPPE has
been reported in different case reports.