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Negative-pressure pulmonary edema (NPPE) is an uncommon diagnosis that requires a high clinical suspicion to recognize and manage and has high morbidity and mortality. It usually results secondary to markedly negative intrapleural pressure due to the forceful inspiration against the obstructed airway from upper airway infection, tumor, or laryngospasm. We present a case of a 27-year-old female with morbid obesity who underwent sleeve gastrectomy and developed NPPE upon emergence from anesthesia. The focus of supportive care should be on addressing the obstruction in the upper airway through either endotracheal intubation or cricothyroidotomy. Additionally, it is important to initiate lung-protective positive-pressure ventilation and promote diuresis, unless the patient is in a state of shock. The resolution of pulmonary edema is typically swift, partially due to the preservation of alveolar fluid clearance mechanisms. In the literature review, we delve into the clinical presentation, pathophysiology, and management of NPPE or post-obstructive pulmonary edema.
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An 81-year-old female with a past medical history of myasthenia gravis presented to the Emergency Department with difficulty breathing. At presentation, the patient also complained of fatigue, diplopia, and ptosis. Vitals and laboratory tests were largely benign. The patient was diagnosed as having a myasthenia gravis exacerbation, which eventually advanced to myasthenic crisis, with the patient requiring admission to the intensive care unit and supplementation of high-flow oxygen. Throughout the course of the patient's hospitalization, the measurements of her negative inspiratory force and vital capacity were found to be normal and unchanged despite shifting and unsteady respiratory symptoms. This uncommon case seeks to highlight the importance of complementing clinical context with the markers of respiratory function to assess the status of myasthenia-related respiratory distress.
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Background and purpose Patients with spontaneous intracerebral haemorrhage have significant morbidity and mortality. One aspect of their care is the need for mechanical ventilation. Extubating a patient safely and efficiently is important in advancing their care; however, traditional extubation criteria using the rapid shallow breathing index and negative inspiratory force do not predict success in these patients as well as they do in other intubated patients. This study aimed to evaluate these criteria in patients with spontaneous intracerebral haemorrhage to improve the extubation success rate. Methods We conducted a retrospective chart review of patients with spontaneous intracerebral haemorrhage (sICH) who underwent spontaneous breathing trials from 2018 to 2020. Twenty-nine patients met the inclusion criteria, and of these 29, 20 had a trial of extubation. Rapid shallow breathing index (RSBI), negative inspiratory force (NIF), and cuff leak were recorded to analyze breathing parameters at the time of extubation. Patients who required reintubation were noted. Results All trials of extubation required a cuff leak. Using RSBI, patients with values <105 or <85, as the only other extubation criteria, were associated with a 70.6% and 71.4% success rate, respectively. With RSBI <105 and NIF <-25 cm water, the success rate was 88.9%. Any patient with a cuff leak that had a NIF <-30 had a success rate of 100%, regardless of RSBI. Conclusion The RSBI was not a reliable isolated measure to predict 100% extubation success. Using a NIF <-30 predicts a 100% extubation success rate if a cuff leak is present. This demonstrates that the NIF may be a more useful metric in sICH patients, as it accounts for patient participation and innate ability to draw a breath spontaneously. Future studies are warranted to evaluate further and optimize the extubation criteria in these patients.
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BACKGROUND: Weaning from mechanical ventilation (MV) is an important and universal issue in critically ill patients, with no consensus that predicts weaning success. Twitch tracheal airway pressure (TwPtr) may be a more objective indicator of diaphragm function. The present study evaluated TwPtr relative to negative inspiratory force (NIF) or Medical Research Council (MRC) score, for predicting success of weaning from MV. METHODS: From December 2015 to March 2017, 62 patients were included who received invasive MV >48 hours and then underwent a test for spontaneous breathing. The NIF and MRC score were sequentially determined. The TwPtr measurement was performed via magnetic stimulation of the neck phrenic nerve. RESULTS: Weaning success was achieved by 54 patients (87.1%), including 30, 12, and 12 patients who experienced simple, difficult, and prolonged weaning, respectively. The areas under receiver operating characteristic curves (AUCs) for NIF, MRC score, and TwPtr were 0.778, 0.560, and 0.792. When TwPtr was combined with NIF, the sensitivity and specificity of weaning success were 96.3% and 75.0%, and AUC was 0.807. In the weaning success group, after correction for age, the AUC of TwPtr was 0.878, which differentiated the simple weaning from non-simple group. CONCLUSIONS: TwPtr was superior to either NIF or MRC score for differentiating patients in the simple weaning group from those patients who experienced difficult, prolonged, or failed weaning. TwPtr combined with NIF may be used to predict weaning success better than the MRC score alone.
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INTRODUCTION: Although formal spirometry is the gold standard for monitoring respiratory function in patients with myasthenia gravis (MG), such testing is often delayed or unavailable. There is a need for a simple bedside test that can accurately measure respiratory function. METHODS: We conducted a prospective, cross-sectional, single-blind study in adults with acetylcholine receptor antibody positive MG. Participants performed the single breath count test (SBCT) and underwent manual muscle strength testing, and a respiratory therapist performed spirometry blinded to SBCT and strength results. RESULTS: Thirty-one patients, aged 57 ± 19 years participated. SBCT showed significant correlations with forced vital capacity (FVC), negative inspiratory force, and neck flexor strength (P < 0.01). FVC showed significant correlation with neck flexor strength (P = 0.02) but no correlation with shoulder abductor strength. CONCLUSIONS: These data suggest that the SBCT and neck flexor strength testing are valuable tools for bedside assessment of respiratory function in MG patients.