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Discussion of Pathophysiology, Treatment, and Prevention

Richard Westreich, MD; Ian Sampson, MD; Christopher M. Shaari, MD; William Lawson, MD, DDS

Arch Facial Plast Surg. 2006;8:8-15.

Objective  To provide rhinologic surgeons with an understanding of acute negative-pressure pulmonary edema (NPPE) and its treatment.

Design  Case report and literature review of all published adult cases of NPPE. Patient factors, anesthetic variables, and outcomes are assessed.

Results  A total of 146 cases in 45 case reports and series were compiled. There was approximately a 2:1 male-female patient ratio. The average age of the patients was 33 years. Fifty percent of patients had surgery on the upper aerodigestive tract, and 8% had intranasal surgery. No patients received laryngotracheal anesthesia, and 5 of the 146 received intravenous lidocaine prior to extubation. One patient had NPPE following laryngeal mask airway treatment, and 2 patients experienced this complication after conversion from monitored anesthesia care to general endotracheal anesthesia; 33.5% of patients were treated with continuous positive airway pressure alone, while 66.5% required intubation and mechanical ventilation. The average time to resolution was 11.75 hours. Three patients died.

Conclusions  It is known that surgical procedures involving the upper aerodigestive tract have a higher risk of NPPE than other procedures. Rapid diagnosis and treatment is necessary to achieve early resolution and avoid significant patient morbidity. A thorough understanding is integral to the practice of nasal and paranasal sinus surgery, especially with the rising use of outpatient and office-based surgical suites. Therefore, we present a review of pathophysiologic mechanisms, possible risk factors, treatment options, and potential steps that can be taken to minimize this potentially devastating complication of general anesthesia.

Author Affiliations: Departments of Otolarynogology (Drs Westreich and Lawson) and Anesthesiology (Dr Sampson), Mount Sinai Hospital, New York, NY; and Division of Head and Neck Cancer, The Cancer Center at Hackensack University Medical Center, Hackensack, NJ (Dr Shaari).

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