An Analysis of Negative Pressure Pulmonary Edema Cases after Acute Upper Airway Obstruction

上呼吸道阻塞引起負壓性肺水腫的案例分析

陳秀屏(Sau-Ping Chan) ； 劉宏濱(Hung-Pin Liu) ； 陳俊宇(Chun-Yu Chen) ； 李君徽(Chun-Hui Lee) ； 洪心慈(Hsin-Tzu Hung) ； 何綺月(Angie CY Ho) ； 楊敏文(Min-Wen Yang) ； 左安順(An-Hsun Chou)

《中華民國急救加護醫學會雜誌》 23卷4期 (2012/12) Pp. 131-138

https://doi.org/10.30018/JECCM.201212.0001

摘要

背景：負壓性肺水腫（NPPE）是一種罕見的臨床症狀，其發生於呼吸道阻塞時，所引起的胸內負壓增加，造成水分移向肺組織間質。而在所有的麻醉合併症中，其發生率是低於0.1%，但如果未被立即發現、確認，其死亡率可高達40%。因此在這項研究中，我們回顧這些案例，探討其發生原因、誘發因素，並提出治療以及預防的建議方式。材料與方法：在通過長庚醫院倫理委員會之審議後，我們透過麻醉品質管理的資料庫中，回顧分析從2006年1月1日至2008年12月31日所有接受全身麻醉的患者，並依據下列情況確認其診斷為負壓性肺水腫：（1）呼吸速率變快；（2）肺部聽診為爆裂音；（3）氣管內管內有粉紅色泡沫狀痰液；（4）脈動氧血紅素飽和度或動脈血氧分析結果為低血氧；（5）胸部X光呈現肺水腫；（6）在24小時內可解決的。同時，在術後我們也會持續追蹤在恢復室或加護單位觀察的患者，一直到症狀改善、氣體交換參數正常及胸部X光正常。結果：在126,589個接受氣管插管全身麻醉的件數中，有13個（0.01%）確認為負壓性肺水腫的案例，其中男性8例、女性5例，均為ASA I或II，年齡分布於11個月至56歲，體重則為9-90公斤。大多數出現肺水腫的案例是發生於氣管插管時或全身麻醉拔管後所引發的上呼吸道阻塞，當重新建立呼吸道、適當的給氧及正壓呼吸器使用，症狀可在24小時內解決。結論：在這次研究中，我們說明了早期被診斷出來、呼吸道重新建立、適當的給氧及正壓呼吸器使用，是有效的治療。當病人呼吸道反射完全恢復時，可以藉由事先鑑別出高危險患者、麻醉誘導時、執行技術輕柔，並在正確的時機拔管，是可以及早被預防發生的。

關鍵字

負壓性肺水腫 ； 上呼吸道阻塞 ； 拔管

並列摘要

Objective: Negative-pressure pulmonary edema (NPPE) occurs when significant negative intrathoracic pressure develops against an obstructed airway, causing fluid to shift into the pulmonary interstitium. NPPE is a rare complication of all anesthetics with an incidence of less than 0.1%. However, the occurrence of NPPE has been suggested to be under-reported, as it is often unrecognized or misdiagnosed. The morbidity and mortality of an unrecognized event of NPPE is as high as 40%. The present study reviews the cases of NPPE and discusses the occurrence, predisposing factors, and recommendations for treatment and prevention.Methods: All patients with general anesthesia from January 1, 2006 through December 31, 2008 were retrospectively analyzed from our Quality Assurance (QA) anesthesiology database. NPPE was diagnosed according to the clinical findings of tachypnea, rales on lung auscultation, pink frothy sputum in the endotracheal tube, hypoxemia on pulse oximetry or on arterial blood gas determination, radiological findings of pulmonary edema, and pulmonary edema which resolved within 24 hours.Results: Of the 126,589 patients who underwent general anesthesia with endotracheal intubation, 13 (0.01%) cases of NPPE were reported (8 males and 5 females). All cases were American Society of Anesthesiologists (ASA) physical status I or II. The age ranged from 11 months to 56 years and the body weight ranged from 9 kg to 90 kg. Most of the patients showed a rapid onset of pulmonary edema after acute upper airway obstruction in the induction and emergency periods. Resolution occurred within 24 hours after reestablishment of airway, adequate oxygenation, and positive pressure ventilation.Conclusions: An early diagnosis of NPPE with reestablishment of the airway, adequate oxygenation, and application of positive airway pressure represent an effective treatment. NPPE can be prevented by identification of high-risk patients, gentle airway manipulation during induction, and extubation at the right time when the patient's airway reflexes have fully recovered.

並列關鍵字

negative pressure pulmonary edema ； upper airway obstruction ； extubation