Post Extubation Pulmonary Edema....HUH?

mcmike55 · Oct 27, 2007

I've seen negative pressure pulmonary edema once.

A pt, with an LMA, breathing on their own, bit down on the LMA, and took a huge deep breath.

Sat's, dropped, bloody frothy sputum up the tube into the cricuit, etc.

Long story short:

Pt spent the night in ICU, medical guy worked him up, all ended well.

Not sure how to avoid other than putting in an oral airway in addition to the LMA, especially in healthy males in that 30-50 ish age group, which I think have increased chances of this.

Live and Learn I guess.

Mike

sleepyrasrn · Oct 27, 2007

I've seen it once and it was mistaken at first as aspiration related until the chest xray came back. A lady in her 70's came in after being found unresponsive in her chair at a nursing home with food all down the front of her. She, apparently, was given a little too much pain medication, her respiratory drive all but stopped and she became hypoxic. She was admitted to the ICU with assumed respiratory distress from aspiration, but the chest xray showed clear lungs and pulmonary edema. She was intubated in the ED and then extubated shortly thereafter on the unit as her respiratory drive rapidly improved. It was short-lived and weird. The assumption was that her decreased respiratory drive caused a negative pressure environment in her lungs (how I don't know) and it caused pulmonary edema. That's what the trauma docs claimed.

drob81 · Oct 27, 2007

this can happen in heart failure pts, though i don't know how common. the increased intrathoracic pressure from the ett can restrict filling pressures within the heart. this can be beneficial in pts with decreased lv function. once the ett is removed, filling pressures may increase which can lead to CHF.

PageRespiratory! · Oct 28, 2007

I've seen it once and it was mistaken at first as aspiration related until the chest xray came back. A lady in her 70's came in after being found unresponsive in her chair at a nursing home with food all down the front of her. She, apparently, was given a little too much pain medication, her respiratory drive all but stopped and she became hypoxic. She was admitted to the ICU with assumed respiratory distress from aspiration, but the chest xray showed clear lungs and pulmonary edema. She was intubated in the ED and then extubated shortly thereafter on the unit as her respiratory drive rapidly improved. It was short-lived and weird. The assumption was that her decreased respiratory drive caused a negative pressure environment in her lungs (how I don't know) and it caused pulmonary edema. That's what the trauma docs claimed.

????????????????????????????????????????????????????????????

CXR showed clear lungs and pulmonary edema?????????????????

Decreased resp. drive = negative pressure in lungs??????????????????????????????????????????????????????

PageRespiratory! · Oct 28, 2007

This was a scary 1st for me....
I extubated a perfectly healthy 50 YO Female s/p lap chole, uneventful, extubation criteria met, wide awake. On extubation she stated she "couldnt breathe", as some pts do have that sensation, she was saturating 100% and was talking, so i reassured her and proceeded down the hallway to the recovery room. She was restless (1st sign) and her color QUICKLY changed to pale...blue....dusky...so of course my life and hers flash before my eyes.....i grab an ambu bag in the recovery room, successfully ventilated her....long story short, she recovers, she did sound very wheezy and stridorous, CXR showed pulmonary edema.
Ofcourse, I am am thinking this thru over and over in my mind....did she have a laryngospasm, she was talking in the OR!!!, it happened so fast, in a matter of 30 seconds....ive read about post-extubation negative pressure PE.....which is what the pulmo and attending thought.....has anyone had anything like this ever happen to them??? What did I miss???? and Yes, i wish i had used a precordial,,,,but hindsight is always 20/20....any thoughts?

Sudden loss of PEEP?? Was she diconnected from vent circuit while still intubated for any length of time?

GilaRRT · Oct 28, 2007

It does happen. You may hear of a condition known as flash pulmonary edema. It can happen in negative pressure type situations. A good example would be a narcotic overdose. You are bagging the patient, narcan is given, then the patient takes a deep breath before you squeeze the bag to inhale and flash pulmonary edema develops.

vaccrn · Oct 29, 2007

I've had this happen to me twice. Once with and LMA (like Mike described) and once was a post extubation laryngospasm. So, what to do about it?

With LMAs - I'm not sure the oral airway will fit very well with the LMA, without distrupting it's seal. I stack 3 4x4s and fold them in half, then wrap them aound the end of a tongue blade and tape in place. I insert this contraption between the molars as far back as possible without disrupting the LMA seal. If the patient wakes up biting, as so many do, they can still exchange air through the LMA.

For post extubation laryngospasm - Don't be too slow to grab the succs. I always have succs available at THE END of the case. And yes, I give 'em a slug of propofol also (I've only had to do this once in the last 2 years by the way) A little prolonged OR time beats all hell outta a night in ICU.

miloisstinky · Nov 4, 2007

Thanks guys, VACCRN,

Im most pee O'd at myself, cause I think she had a laryngospasm in the friggin hallway and i didnt notice it!!!!!!!! Im gonna ask another question on a new thread re waiting time before leaving the OR.....thanks!