Negative-Pressure Pulmonary Edema After Difficult Endotracheal Intubation in a Patient with Juvenile Rheumatoid Arthritis Undergoing Spigelian Hernia Surgery: A Case Report

Abstract

Patient: Male, 35-year-old Final Diagnosis: Negative-pressure pulmonary edema Symptoms: Difficult airway management Medication:— Clinical Procedure: — Specialty: Anesthesiology • Critical Care Medicine Objective: Unusual clinical course Background: Difficult tracheal intubation (DTI) is common in patients with rheumatoid arthritis (RA) because of the subluxation of atlas and axis, the fusion of the cervical spine as a result of arthritis. We report a case of negative-pressure pulmonary edema (NPPE) caused by DTI in a patient with juvenile RA (JRA) who underwent surgery for spigelian hernia. Case Report: A 35-year-old man was referred to our department for repeated abdominal pain and a left-lower quadrant mass. Spigelian hernia was diagnosed with abdominal computed tomography (CT), and surgery was scheduled. Despite careful preoperative preparation and intubation strategy, fiber-optic intubation and laryngeal mask ventilation failed; nasal fiber-optic tracheal intubation was subsequently successfully performed. During induction, upper airway obstruction caused NPPE. CT findings showed bilateral infiltration and diffuse ground-glass opacity suggestive of pulmonary edema. Surgery for the spigelian hernia was canceled as the patient required intensive care as a result of NPPE. After 48 h of initiating treatment, the patient’s respiratory condition gradually improved. Seven days after DTI, he underwent laparoscopy-assisted surgery for the spigelian hernia. The patient was discharged after 2 weeks of hospitalization. Four years have passed since the surgical procedure; the outcome has remained favorable and there has been no recurrence. Conclusions: Normal ventilation may be the most important factor for preventing NPPE. It is vital that patients with RA receive treatment in an environment with advanced airway equipment and staff fully trained in its use. Similarly, the necessary staff and equipment for emergency cricothyroidotomies should also be readily available.

Negative pressure pulmonary edema (Review)

“…Several studies have reviewed cases that included risk factors for perianaesthesia-induced NPPE, such as obesity with obstructive sleep apnea and anatomical intubation difficulties, as well as nasal, pharyngeal and laryngeal surgery or disease (35)(36)(37). Patients with the aforementioned risk factors should preferably undergo awake intubation, as they may be at increased risk of airway complications following extubation performed after general anesthesia; therefore, optimal upper airway muscle tone is ensured in these patients (36).…”