Prevention Strategies for Laryngospasm-Induced Negative Pressure Pulmonary Edema: A Case Report

Document Type

Conference Proceeding

Publication Date

5-9-2025

Abstract

Laryngospasm-induced negative pressure pulmonary edema (NPPE) is referred to as Type I NPPE, and occurs immediately after an acute airway obstruction. Prevalence rates of NPPE have been reported at 0.05 - 0.1% of general anesthesia cases with tracheal intubation (Budhathoki & Wu, 2020). Additional studies found that of laryngospasm cases requiring active intervention for acute upper airway obstruction, 11% developed NPPE (Westreich et al, 2006). Typical treatment includes administration of succinylcholine to maintain a patent airway, supplemental oxygen, continuous positive airway pressure, and furosemide. This case report details what happens when the operating room anesthesia cart is not properly stocked with succinylcholine, and discusses interventions that may enhance patient safety during and after general anesthesia.

A 36 year old male with a history of sleep apnea was struck by a vehicle while riding his bike. The patient was wearing a helmet and struck the car's windshield during the collision. No loss of consciousness was reported. The patient presented to the Emergency Room in a C collar with no reported loss of consciousness and slight disorientation. The patent had no past surgical history, was not currently taking medications, and was a smoker. A 3D CT scan confirmed nasal and maxillary bone fractures. The patient reported a sulfa allergy, had no history of anesthetic complications, and a Mallampati III airway. On the day of surgery, the patient underwent general endotracheal anesthesia for the repair of fractures to the nasal and maxilla bones. Shortly after extubation, the patient experienced a laryngospasm followed by acute respiratory distress with pink frothy sputum. The refractory laryngospasm was recognized promptly, however, succinylcholine was not available in the operating room.

In the SICU, a chest x-ray and bronchoscopy were performed. Diffuse, bilateral pulmonary infiltrates and normal heart size were visible on the x-ray, which is consistent with pulmonary edema. Blood was visualized on bronchoscopy and otherwise unremarkable. On post-op days one, the patient was mechanically ventilated and given furosemide twice daily. A chest x-ray confirmed that pulmonary edema was improving, however, the patient failed a spontaneous breathing trial and remained on the ventilator. On post-op day two, another chest x-ray was taken and showed improvement. The patient passed the spontaneous breathing trial was discharged home a few days later.

The take home message is that succinylcholine should always be stored in OR. This case indicates an opportunity for systematic improvement in the OR, routine pyxis drug checks either need to be more thorough or more frequent, another option is to have emergent drugs stored in another supply area in the OR as a backup. This case exemplifies fairly routine NPPE as the patient was young, healthy, and had a good reason (aspiration of blood) for vocal cord irritation. This case also exemplifies good management with application of positive pressure ventilation and diuresis.

Comments

2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025. Abstract 1857

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