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Atypical Presentation of Negative Pressure Pulmonary Edema FREE TO VIEW

John Kern, DO; Khaleb Abu-Ihweij, MD; Samir Abdelhadi, MD; Zaza Cohen, MD
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Rutgers University - New Jersey Medical School, Oceanport, NJ

Chest. 2015;148(4_MeetingAbstracts):1024A. doi:10.1378/chest.2278565
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SESSION TITLE: Signs and Symptoms of Chest Diseases Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Negative pressure pulmonary edema is an etiology of non-cardiogenic pulmonary edema typically associated with upper airway obstruction post extubation.

CASE PRESENTATION: A 73 year-old woman with hypertension, anxiety, and lung cancer treated with lobectomy presented with severe dyspnea requiring intubation in the field following a panic attack. Chest x-ray demonstrated pulmonary edema which resolved after intubation. She was immediately extubated in the emergency department and did well. Extensive cardiac evaluation was negative. The patient had two more episodes of dyspnea, precipitated by anxiety, requiring intubation with resolution of symptoms immediately following intubation. Laryngoscopy revealed laryngeal spasm. She was diagnosed with negative pressure pulmonary edema (NPPE) due to vocal cord dysfunction and treated with botulinum toxin injection locally. She had a partial response to botulinum toxin injection, but eventually required tracheostomy.

DISCUSSION: NPPE in the setting of vocal cord dysfunction is an exceedingly rare phenomena. NPPE occurs when there is a rapid increase in the negative intrathoracic pressure due to inspiration against an obstructed upper airway coupled with a catecholamine surge precipitating increased systemic vascular resistance leading to pulmonary edema [1]. NPPE is almost exclusively found immediately post extubation, however, in our case, the episodes would occur days or even weeks after extubation. In our patient, the events were preceded by states of anxiety and panic, further indicating a role of vocal cord dysfunction. Botulinum toxin injections have been shown to avert tracheostomy in patients with vocal cord dysfunction [2], but were only partially effective in our patient, potentially due to her non-compliance with the medical regimen.

CONCLUSIONS: This is one of only a few reported cases of NPPE secondary to vocal cord dysfunction occurring outside the common setting of post extubation. Upper airway obstruction and NPPE must be included in the differential diagnosis of a patient with non-cardiogenic pulmonary edema.

Reference #1: 1. Mulkey, Z., Yarbrough, S., Guerra, D., et al. (2008). Postextubation pulmonary edema: a case series and review. Respir Med, 102(11), 1659-1662.

Reference #2: 2. Daniel, S. J., & Cardona, I. (2014). Cricothyroid onabotulinum toxin A injection to avert tracheostomy in bilateral vocal fold paralysis. JAMA Otolaryngol Head Neck Surg, 140(9), 867-869.

DISCLOSURE: The following authors have nothing to disclose: John Kern, Khaleb Abu-Ihweij, Samir Abdelhadi, Zaza Cohen

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