Negative pressure pulmonary hemorrhage induced by a candy
i An update to this article is included at the end
Pulmonary hemorrhage i”>American Journal of Emergency Medicine (2010) 28, 112.e3-112.e5
Case Report
Negative pressure pulmonary hemorrhage induced by a candy
Abstract
Negative pressure pulmonary edema, a well-recognized phenomenon, is the formation of pulmonary edema after an acute upper airway obstruction, but pulmonary hemorrhage associated with negative-pressure pulmonary edema is rare. Vigorous inspiratory efforts against an obstructed upper airway (the modified Mueller maneuver) led to the development of acute negative-pressure pulmonary edema. We describe a case of negative pressure pulmonary hemorrhage induced by a candy. The patient required short-term ventilation with contin- uous positive airway pressure (12 cm H2O) by face mask with Rapid resolution of clinical and radiological findings. Negative pressure pulmonary edema may present as pulmonary hemorrhage and require positive-pressure ventilatory support for some time. The mechanism for pulmonary hemorrhage associated with negative pressure pulmonary edema is not clear, but disruption of the alveolar-capillary membrane caused by large negative pressure swings is most likely.
A healthy boy aged 13 years choked while eating a candy, and Heimlich maneuver was immediately per- formed. The apparent airway obstruction was improved, but he continued to cough vigorously, producing blood- stained frothy sputum. He also reported increasing dyspnea. On admission to the hospital 2 hours after the incident, the patient was still coughing and pulse oximetry showed an oxygen saturation of 82% on room air. Initial assessment of arterial blood gases with fraction of inspired oxygen of 40% showed pH 7.42, PO2 66 mm Hg, PCO2 35 mm Hg, and HCO3 22 mmol/L. On chest examination, poor air entry and coarse crackles were present. Chest radiographs revealed bilateral, widespread alveolar opacities. No pleural effusion, mediastinal pedicle, or cardiac enlargement are seen. No radio-opaque foreign body was visible (Fig. 1). An electrocardiogram revealed a sinus tachycardia. However, acute airway
obstruction by a foreign body was suspected and the patient underwent urgent rigid bronchoscopy. No foreign body was found, but copious frothy bloody secretions were suctioned from both main bronchi. The endobron- chial mucosa was normal and was without masses or an identifiable bleeding source. A bronchalveolar lavage (BAL) was performed to help clarify the origin of the bleeding. The cytology was negative for hemosiderin- laden macrophages, and all cultures were negative. After rigid bronchoscopy the patient became restless and was unable to maintain adequate oxygenation. The patient was transferred to the intensive care unit for a short-term ventilatory support, with application of positive pressure to the airway. Ventilation with continuous positive airway
Fig. 1 Chest radiograph revealed bilateral, widespread alveolar opacities. No pleural effusion, mediastinal pedicle, or cardiac enlargement are seen. No radio-opaque foreign body was visible.
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112.e4 Case Report
Fig. 2 A computed tomography scan of the chest showed bilateral consolidations and Ground glass opacities without prevalence in dependent or not dependent regions. No pleural effusion is seen.
pressure (12 cm H2O) was begun by face mask and continued for 12 hours. A computed tomography scan of the chest showed bilateral consolidations and ground glass opacities without prevalence in dependent or not depen- dent regions. No pleural effusion is seen (Fig. 2A-B). Treatment with steroids, diuretics, bronchodilators, and Intravenous antibiotics (piperacillin sodium and the b- lactamase inhibitor tazobactam) was started. In this case, the onset (within minutes) and resolution were rapid, with a significant clinical and radiographic improvement in 24 hours. The patient’s oxygen requirement decreased progressively over the ensuing 24 hours, and he remained
stable thereafter. Before the patient’s discharge on hospital day 3, a chest radiograph showed strong improvement of bilateral alveolar opacities.
Negative pressure pulmonary edema, a well-recognized phenomenon, is the formation of pulmonary edema after an Acute upper airway obstruction [1-3] with a reported incidence as high as 11% [4]. However, pulmonary hemorrhage associated with negative-pressure pulmonary edema is rare [5]. Vigorous inspiratory efforts against an obstructed upper airway (the modified Mueller maneuver) led to the development of acute negative-pressure pulmonary edema. It is reported more commonly in young patients after surgery when laryngospasm compli- cates extubation. It is also described in intensive care unit patients after endotracheal tube occlusion and in children with epiglottitis. Negative-pressure pulmonary edema is characterized by a rapid onset (within minutes) and resolution, with a significant clinical and radiographic improvement in 12 to 24 hours [1,5,6]. To our knowl- edge, diffuse alveolar hemorrhage has not been reported previously as a complication of negative-pressure pul- monary edema induced by a candy. Most patients require temporary intubation and positive end-expiratory pressure. Diuresis and/or fluid restriction are often used. We describe a case of negative pressure pulmonary hemor- rhage, and probably its etiology is stress failure, the mechanical disruption of the alveolar-capillary membrane. The negative intrathoracic pressure increases right-sided cardiac filling, raising Pulmonary arterial pressure and thereby pulmonary capillary pressure with transudation into the interstitial and alveolar spaces [1,5-7]. Negative pressure pulmonary hemorrhage usually resolves rapidly with short-term ventilatory support, the main treatment being early application of positive pressure to the airway. Adjunctive treatment with steroids, diuretics, and bronch- odilators has been proposed, but their contribution to management is unclear [1,6,7].
Gian Luca Casoni MD
Sara Tomassetti
Dipartimento Toracico Ospedale GB Morgagni, 47100 Forli, Italy E-mail addresses: [email protected]
Angelo Coffa
Dipartimento Emergenza Ospedale GB Morgagni, 47100 Forli, Italy
Claudia Ravaglia Venerino Pol Dipartimento Toracico
Ospedale GB Morgagni, 47100 Forli, Italy
doi:10.1016/j.ajem.2009.02.027
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- McConkey PP. Postobstructive pulmonary oedema-a case series and review. Anaesth Intensive Care 2000;28:72-6.
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- Tami TA, Chu F, Wildes TO, et al. Pulmonary edema and acute upper airway obstruction. Laryngoscopy 1986;96:506-8.
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Update
American Journal of Emergency Medicine
Volume 28, Issue 4, May 2010, Page 534
DOI: https://doi.org/10.1016/j.ajem.2010.03.019
American Journal of Emergency Medicine (2010) 28, 534
Errata
In the article “systemic manifestations following ingestion of small amounts of Acetic acid by a child,” published in Am J Emerg Med 2007;25(6):738.e1-738.e2, the author names were listed incorrectly. The Correct byline is below.
Yonatan Yeshayahu MD, MHA, Dan Engelhard MD.
DOI of original article: 10.1016/j.ajem.2007.01.015. doi:10.1016/j.ajem.2010.03.018
The article, “Negative pressure pulmonary hemorrhage induced by a candy,” published in Am J Emerg Med 2010;28(1): 112.e3-112.e5 had an error in the byline. The correct name of the last author is Venerino Poletti.
DOI of original article: 10.1016/j.ajem.2009.02.027. doi:10.1016/j.ajem.2010.03.019
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