Post-extubation negative pressure pulmonary edema following acute upper airway obstruction in a young athlete: a case report

Abstract Background Negative pressure pulmonary edema (NPPE) is a non-cardiogenic hemodynamic pulmonary edema resulting from significant inspiratory effort against obstructed airways. Although rare, it is a recognized cause of postoperative respiratory distress and can mimic differential diagnoses. Patients most predisposed to this condition are muscular or athletic individuals, due to their ability to generate significant negative intrathoracic pressure. Case presentation An 18-year-old male patient underwent a laparoscopic appendectomy under general anesthesia with tracheal intubation. Two minutes after extubation, the patient developed acute respiratory distress with salmon-pink sputum. Lung auscultation revealed bilateral crackles, associated with desaturation and cyanosis, occurring in the context of acute obstruction of the upper airways during anesthetic awakening. A pleuro-pulmonary ultrasound performed according to the Bedside Lung Ultrasound in Emergency (BLUE) protocol showed a bilateral B-line pattern with preserved pleural sliding. Transthoracic echocardiography showed preserved left ventricular function with non-elevated filling pressures, allowing the rapid exclusion of a cardiogenic origin. Chest radiography demonstrated perihilar alveolar opacities consistent with pulmonary edema. A diagnosis of negative pressure pulmonary edema was thus made. Management consisted of a semi-sitting position at 30°, oxygen therapy, and non-invasive ventilation, without the use of diuretics. Clinical improvement was observed within the first 2 hours, with normalization of blood gases and radiological improvement within 24 hours. Conclusion Negative pressure pulmonary edema (NPPE) should be considered a cause of post-extubation respiratory distress, particularly in young muscular patients. The integration of pleuro-pulmonary ultrasound and transthoracic echocardiography allows for rapid diagnostic guidance at the patient's bedside. Positive pressure ventilation remains the cornerstone of treatment.