2025 FSA Podium and Poster Abstracts

Background: Negative pressure pulmonary edema (NPPE) is an uncommon but serious complication arising from forceful inspiratory efforts against a closed glottis, often due to laryngospasm. It is most frequently observed in young, healthy patients with strong respiratory muscles. This case highlights the rapid onset and successful management of NPPE following laryngospasm in a healthy adolescent undergoing general anesthesia for hand fracture repair.

Case Description: A 16-year-old male (ASA I) with no significant past medical history presented for open reduction and internal fixation of a metacarpal fracture under general anesthesia. Anesthesia was induced with propofol and fentanyl, followed by rocuronium to facilitate endotracheal intubation. The intraoperative course was uneventful. During emergence, despite administration of sugammadex for neuromuscular blockade reversal, the patient developed severe laryngospasm upon extubation. Initial maneuvers, including jaw thrust, positive pressure ventilation, and deepening anesthesia with propofol, failed to relieve the obstruction. The patient exhibited forceful inspiratory efforts against a closed glottis, prompting administration of succinylcholine (1 mg/kg). The laryngospasm resolved, and the airway was successfully re-established with mask ventilation. Shortly after, the patient developed tachypnea, oxygen desaturation (SpO2 85% on 6L NC), and pink frothy secretions. Chest auscultation revealed diffuse rales, and a chest X-ray demonstrated bilateral pulmonary infiltrates consistent with NPPE. The patient was managed with non-invasive positive pressure ventilation, supplemental oxygen, and supportive care, leading to rapid clinical improvement. He was observed in the post-anesthesia care unit for 24 hours, with complete resolution of symptoms and radiographic findings.

Discussion: NPPE, particularly Type I, results from a sudden increase in negative intrathoracic pressure secondary to upper airway obstruction. This leads to increased pulmonary capillary hydrostatic pressure, alveolar capillary membrane disruption, and pulmonary edema. Risk factors include young age, male sex, strong inspiratory effort, and recent extubation, all of which were present in this case. Recognition of tachypnea, hypoxia, and frothy secretions post-extubation is critical to timely diagnosis. Management involves airway support, supplemental oxygen, and positive pressure ventilation, with diuretics used judiciously based on volume status. Most cases resolve within 24–48 hours without long-term sequelae. Conclusion: This case underscores the importance of early recognition and treatment of NPPE, particularly in healthy, young patients following laryngospasm. Anesthesia providers should remain vigilant during extubation and have a high index of suspicion for NPPE when respiratory distress occurs postoperatively. Proactive strategies, including careful airway management and early application of CPAP, may help reduce the incidence of this complication.