Veno-Venous Extracorporeal Membrane Oxygenation - Rapid Recovery for Post-Surgical Negative Pressure Pulmonary Edema

Introduction Postoperative pulmonary edema can be cardiogenic, non-cardiogenic or a combination of both. A major cause of noncardiogenic edema is negative pressure pulmonary edema (NPPE) due to inspiration against a closed glottis. Within minutes, patients can develop dyspnea and pink tinged frothy sputum. Risk factors include a short neck, obstructive sleep apnea, and previous ENT surgeries. There have also been a few case reports that demonstrate NPPE after the use of sevoflurane. Below we present a case of a young female who developed post-surgical NPPE which was managed with short-term veno-venous extracorporeal membrane oxygenation (V-V ECMO). Case Report A 30-year-old female with minimal past medical history was airlifted to the cardiovascular intensive care unit four hours after a condyloma removal under sevoflurane anesthesia with a laryngeal mask airway. The patient developed post-operative hypoxia and hemoptysis requiring intubation. A computerized tomography (CT) scan of the chest with contrast revealed ground-glass opacities concerning for diffuse alveolar hemorrhage (DAH). Upon arrival, a bronchoscopy with sequential lavages revealed persistently sanguineous fluid which pointed away from active alveolar hemorrhage. The ECMO team was consulted due to concerns for acute lung injury. Given the preserved cardiac function, the patient was placed on V-V ECMO for two days with rapid recovery of lung function. The patient was maintained on ventilator support for two additional days before being discharged on the fifth day. Summary The mainstay of treatment for NPPE is supportive care. Most patients require prolonged monitoring in the postanesthesia care unit and usually recover within a few hours with supplemental oxygen and continuous positive end-expiratory pressure. Occasionally, patients will need to be intubated. In this case, the post-procedural CT scan showed no signs of cardiogenic pulmonary edema, but rather DAH. Given ventilation difficulties with adequate cardiac function, the patient was an appropriate candidate for V-V ECMO. The DAH could possibly be due to sevoflurane but was more likely a consequence of NPPE. Regardless of the cause, the use of V-V ECMO is highly effective in allowing patients to rapidly recover respiratory function without long-term complications.