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(Chest. 2005;127:1867-1868.)
© 2005 American College of Chest Physicians

Negative Pressure Pulmonary Edema as an Unsuspected Imitator of Acute Lung Injury/ARDS

Gareth L. Ackland, PhD and Michael G. Mythen, MD

University College London, London, UK

Correspondence to: Gareth L. Ackland, PhD, Centre for Anaesthesia, University College London, The Middlesex Hospital, Mortimer St, London W1T 8AA, UK; e-mail: g.ackland{at}rfc.ucl.ac.uk

To the Editor:

Further to the recent review article by Schwarz and Albert1 (April 2004), we would like to add negative pressure pulmonary edema (NPPE) as a further important imitator. NPPE may rarely fall into the category of diffuse alveolar hemorrhage (DAH) through damage of the pulmonary capillaries by mechanical disruption of the alveolar-capillary membrane, resulting in diffuse alveolar injury. More usually, pulmonary edema is manifest, with fulfillment of the clinical, physiologic, and radiographic criteria for acute lung injury (ALI)/ARDS. Several hypotheses have been postulated to explain the pathophysiologic sequelae of NPPE.2345 While early recognition and specific treatment of an underlying condition23456789 may rule in NPPE or rule out other causes of DAH, an obvious underlying cause may be absent particularly after emergence from anesthesia or unwitnessed upper airway obstruction. Indeed, symptoms of NPPE may be considerably delayed after extubation.9 Although symptoms usually resolve rapidly with restoration and/or maintenance of a patent airway and supplemental oxygen, positive end-expiratory pressure and mechanical ventilation may be required for a prolonged period of time.10 Failure to consider NPPE in the differential diagnosis of acute clinical, physiologic, and radiographic changes that fit the criteria for ALI/ARDS may lead to unnecessary and potentially deleterious iatrogenic complications.

References

  1. Schwarz, MI, Albert, RK (2004) "Imitators" of the ARDS: implications for diagnosis and treatment. Chest 125,1530-1535[Free Full Text]
  2. Kollef, MH, Pluss, J Noncardiogenic pulmonary edema following upper airway obstruction. Medicine 1991;70,91-98[Medline]
  3. Palvin, DJ, Nersley, ML, Cheney, FW Increased pulmonary vascular permeability as a cause of re-expansion pulmonary oedema. Am Rev Respir Dis 1981;124,422-427[ISI][Medline]
  4. Shwartz, D, Maroo, A, Malhotra, A Negative pressure pulmonary haemorrhage. Chest 1999;115,1194-1197[Abstract/Free Full Text]
  5. Lorch, DG, Sahn, SA Post-extubation pulmonary oedema following anaesthesia induced by upper airway obstruction: are certain patients at increased risk? Chest 1986;90,802-805[Abstract/Free Full Text]
  6. Oswalt, CE, Gates, GA, Holmstrom, MG Pulmonary edema as a complication of acute airway obstruction. JAMA 1977;238,1833-1835[Abstract]
  7. Koh, MS, Hsu, AA, Eng, P Negative pressure pulmonary oedema in the medical intensive care unit. Intensive Care Med 2003;29,1601-1604[CrossRef][ISI][Medline]
  8. Devys, JM, Balleau, C, Jayr, C, et al Biting the laryngeal mask: an unusual cause of negative pressure pulmonary edema. Can J Anaesth 2000;47,176-178[Abstract/Free Full Text]
  9. Cascade, PN, Alexander, GD, Mackie, DS Negative-pressure pulmonary edema after endotracheal intubation. Radiology 1993;186,671-675[Abstract/Free Full Text]
  10. Dolinski, SY, MacGregor, DA, Scuderi, PE Pulmonary hemorrhage associated with negative-pressure pulmonary edema. Anesthesiology 2000;93,888-890[ISI][Medline]




This Article
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