Differential Diagnosis of Negative Pressure Pulmonary Edema During COVID-19 Pandemic

Abstract

Negative pressure pulmonary edema (NPPE) is a form of noncardiogenic pulmonary edema that typically occurs in response to an upper airway obstruction, where patients generate high negative intrathoracic pressures, leading to a pulmonary edema especially in the postoperative period. Here, we report a case of NPPE following general anesthesia that can easily be misdiagnosed as COVID-19 both radiologically and clinically during this pandemic. Twenty-year-old male was presented with sudden onset respiratory distress, tachypnea, and cyanosis just after the rhinoplasty surgery under general anesthesia. Chest radiography and thoracic computed tomography scans revealed the bilateral patchy alveolar opacities with decreased vascular clarity that looks similar to COVID-19 radiology. Negative pressure pulmonary edema is a sudden onset and life-threatening complication following general anesthesia particularly after head and neck surgery in young healthy individuals. It is a clinical condition that cannot be diagnosed unless it comes to mind. While both NPPE and COVID-19 cause hypoxemia and respiratory distress, as well as ground-glass opacities in the chest computed tomography, those opacities in NPPE appear mostly in central areas, whereas those opacities are mostly seen in peripheral areas in COVID-19. Furthermore, while NPPE cause decreased vascular clarity, COVID-19 causes vascular dilatations in the areas of opacities. Those differences together with medical history of the patient is crucial to differentiate these 2 similar identities. Negative pressure pulmonary edema requires an immediate recognition and intervention, therefore, we would like to raise the awareness of clinicians for such condition to avoid possible mistakes during the pandemic situation.

Negative pressure pulmonary edema following laryngospasm after dental abscess: A case report

“…Characteristic chest radiographic findings consistent with the diagnosis include bilateral focal pulmonary infiltrates, extensive vascular pedicles, and a normal cardiothoracic ratio [ 4 ]. Another accurate and commonly used imaging modality is CT, which is gaining popularity for diagnosing this disorder, and its typical findings include accentuated consolidation with surrounding ground-glass opacity suggestive of pulmonary edema [ 23 ].…”

“…This cascade of events can ultimately lead to the formation of a periapical abscess, radicular cyst, or periapical granuloma [ 1 , 2 ]. Negative pressure pulmonary edema (NPPE), also known as post-obstructive pulmonary edema, is a rare and life-threatening condition that follows the vigorous relief of upper airway obstruction during extubation in a spontaneously breathing patient after general anesthesia or negative thoracic pressure induced by inspiratory effort against an obstructed glottis [ 3 , 4 ]. However, it can be caused by laryngospasm, epiglottitis, tumors, obesity, hiccups, or obstructive sleep.…”

Atypical negative pressure pulmonary edema after extracorporeal membrane oxygenation therapy forCOVID‐19

“…Acute respiratory failure after intense inspiratory effort against an obstructed airway has been well‐described as NPPE, and some authors have discussed the differential diagnoses of NPPE and COVID‐19 pneumonitis. 1 , 2 Typical NPPE imaging findings reportedly involve preferential central and nondependent distribution without exception. This atypical type of NPPE would have been a very rare case before the COVID‐19 pandemic.…”

“…Given this clinical course, the pulmonary shadows were attributed to negative pressure pulmonary edema (NPPE). Acute respiratory failure after intense inspiratory effort against an obstructed airway has been well‐described as NPPE, and some authors have discussed the differential diagnoses of NPPE and COVID‐19 pneumonitis 1,2 . Typical NPPE imaging findings reportedly involve preferential central and nondependent distribution without exception.…”

What We Learned from COVID-19: From endotheliitis to treatment

“…Novel coronavirus disease 2019 (COVID-19) has resulted in a dramatic pandemic crisis by causing mainly a respiratory disease that can rapidly progress to pneumonia and, in severe cases, to acute respiratory distress syndrome (ARDS) 1 . Globally, as of May 9 th of 2021, there have been 157,289,118 confirmed cases of COVID-19, including 3,277,272 deaths, reported to World Health Organization (WHO) 2 .…”