In 2001, 2029 patients underwent surgery at the Victorian Plastic Surgery Unit in Melbourne, Australia. Of these, approximately 50% had cosmetic surgery. In 2 of these cosmetic surgery patients, pulmonary edema associated with laryngospasm developed.

Case 1

A 36-year-old man was admitted for an elective cosmetic rhinoplasty procedure. His medical history included a fractured nose, a shoulder reconstruction, and an appendectomy without complications. He was intubated with a size 8.5 endotracheal tube. Medications included midazolam, propofol, vecuronium, morphine, sevoflurane, droperidol, ondansetron, and clonidine. During surgery, no problems were noted. Oxygen saturation was maintained at more than 97% throughout surgery.

After surgery, in the recovery unit, the patient exhibited a marked cough; his oxygen saturation decreased to 60%, and right-side crepitations were detected on auscultation. Oxygen saturation improved with bag and mask ventilation. Chest radiography revealed bilateral pulmonary congestion. He was reintubated 1 hour after surgery and received 200 mg of furosemide. During reintubation, frothy pink sputum was noted.

The patient was transferred to an intensive care unit, where positive ventilation was continued for a total of 17 hours. Serial chest radiographs showed a resolving alveolar opacity that was most marked in the right lung (Figure 1). Electrocardiography showed no ischemic changes. The patient was also treated with ceftriaxone and metronidazole, although there was no evidence of infection. The patient recovered fully and was discharged 5 days after surgery.

Resolving pulmonary edema, most marked in the right lung, was revealed in the radiograph of a patient who had undergone elective cosmetic rhinoplasty.

Case 2

A 34-year-old woman was admitted for bilateral augmentation mammaplasty and suction-assisted lipoplasty of the thighs and buttocks. She was being treated for depression with sertraline and had mild exercise-induced asthma that was treated with aerolized albuterol. Her history included a rhinoplasty that had resulted in no complications.

Anesthesia, administered with a size 7 endotracheal tube, included midazolam, atracurium, fentanyl, morphine, a N2O/O2 mix, and isoflurane. The intraoperative course was uncomplicated. During extubation she was noted to be coughing while still on the endotracheal tube and biting the tube, causing near-total obstruction. Oxygen saturation at this time was maintained at more than 96%.

However, in the recovery unit, 10 minutes after the patient was extubated, severe laryngospasm developed, and oxygen saturation decreased to 67%. Bilateral crepitations were noted on auscultation. A chest radiograph revealed severe bilateral pulmonary edema (Figure 2). Treatment included furosemide, a glyceryl trinitrate patch, and high-flow oxygen in the high-dependency unit. We detected no ECG abnormality or increase in troponin I. The patient recovered completely and was discharged home on the fourth postoperative day.

Severe bilateral pulmonary edema was demonstrated on the radiograph of a woman who had undergone augmentation mammaplasty and suction-assisted lipoplasty of the thighs and buttocks.

Discussion

Background

Negative pressure pulmonary edema (NPPE) is an uncommon condition that occurs in the setting of upper-airway obstruction at the time of emergence from general anesthesia in a spontaneously breathing patient. It is potentially fatal if it goes unrecognized or is misdiagnosed.

Oswalt, in 1977, was the first to report clinical cases of pulmonary edema associated with acute upper-airway obstruction. In 1980, Jackson first described a case of postextubation laryngospasm-induced pulmonary edema. Lang, in 1990, and Deepika, in 1997, reported 77 cases and 30 cases respectively. To our knowledge, no other report of NPPE in a patient undergoing cosmetic surgery has been published.

Although it is a recognized perioperative problem, NPPE is probably underreported and frequently misdiagnosed. The true incidence is not known, but it has been estimated to range from 0.05% to 0.1% of general anesthetic procedures. NPPE has also been referred to by other terms (eg,“laryngospasm-induced pulmonary edema,” “noncardiogenic pulmonary edema,” “obstructive pulmonary edema,” and “postextubation pulmonary edema”), which has contributed to the confusion over its actual incidence. The purpose of this report is to summarize the published data and discuss their implications in the clinical setting of plastic surgery practice.