# 228 When it sucks to be blue.
The concept of Negative Pressure Pulmonary Edema, in my opinion, is not one that is well known as it should be among all levels of rescuers and resuscitationists, as skill in opening the airway at all times is essential. Patients who struggle against an inadequately open airway must use greater effort and negative force to breathe. Hydrostatic changes in the lung cause fluid shift into the alveoli. It is also known as Post-Obstructive Pulmonary Edema. Guarding the patency and efficiency of the airway is a principal duty. NPPE may occur during procedural sedation.
Vigilance should be high if there is altered mental status with decreased alertness and an unsupported natural airway. Airflow should be open and easy throughout the cycle. Best known following frank obstructive episodes after extubation, laryngospasm, tube-biting, ventilator dyssynchrony, choking, or hanging. Might it be a component of lesser incidents such as those "sleeping it off", opioid overdose pulmonary edema, or stupor with obstructive sleep apnea?
Fix obstruction or laryngospasm immediately. Remove stimulus (secretions). Onset may be immediate or slightly delayed. Oxygen and PEEP are most useful. CXR confirms. A diuretic is controversial but thought possibly useful if there is much swelling or refractory response. In critical cases, ventilatory support, proning, or ECMO may be needed. Resolution within 12 – 48 hours.
Hu, Kami, MD. Negative-Pressure Pulmonary Edema. UMEM Educational Pearls. University of Maryland, Department of Emergency Medicine. 09/12/2017.
Bhattacharya, M., Kallet, R. H., Ware, L. B., & Matthay, M. A. (2016). Negative-pressure pulmonary edema. CHEST Journal, 150(4), 927-933. [PDF]
Nickson, Chris, Dr. Negative Pressure Pulmonary Oedema. Life In The Fast Lane. 12 May 2014.
Shipley, Cal, MD. Pulmonary Edema - Negative Pressure video - Animation by Cal Shipley, M.D. YouTube.
Zhurda, T., Muzha, D., Dautaj, B., Kurti, B., & Marku, F. (2016). Acute Postoperative Negative Pressure Pulmonary Edema as Complication of Acute Airway Obstruction: Case Report. J Anesth Clin Res, 7(603), 2. [PDF]
Horng, H. C., Ho, M. T., Huang, C. H., Yeh, C. C., & Cherng, C. H. (2010). Negative pressure pulmonary edema following naloxone administration in a patient with fentanyl-induced respiratory depression. Acta Anaesthesiologica Taiwanica, 48(3), 155-157.
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