Anesth Pain Med.  2024 Apr;19(2):144-149. 10.17085/apm.23101.

Early diagnosis of negative-pressure pulmonary edema presenting as diffuse alveolar hemorrhage using lung ultrasonography -A case report-

• Son HW
• Kang Y
• Ahn Y
• Oh J

• KMID: 2555251
• DOI: http://doi.org/10.17085/apm.23101

Abstract

Background
Diffuse alveolar hemorrhage (DAH) is a potentially life-threatening condition that can occur due to a variety of disorders. Hence, rapid diagnosis and prompt initiation of appropriate treatment are imperative. Case: A 55-year-old woman with a deep neck infection underwent emergent tonsillectomy. General anesthesia and surgery proceeded uneventfully. Upon transfer to the post-anesthesia care unit, ongoing respiratory distress and occasional expectoration of blood-tinged sputum were noted. Lung ultrasonography (LUS) revealed multiple B-profiles and irregular pleural lines with subpleural consolidations. Emergent bronchoscopy with bronchoalveolar lavage was diagnostic of DAH. She underwent a comprehensive evaluation for rheumatologic and infectious etiologies of DAH, all of which yielded negative results. The patient was managed with steroids and conservative treatment.
Conclusions
The integration of LUS with clinical information allows for more rapid differentiation of acute respiratory failure causes. Therefore, anesthesiologists’ awareness and utilization of LUS findings of DAH can significantly contribute to appropriate management.

Keyword

Postoperative complication; Postoperative hemorrhage; Pulmonary edema; Sevoflurane; Tonsillectomy; Ultrasonography

Figure

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  Fig. 1. Chest X-ray depicted no pathological findings–despite the patient’s symptoms.

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  Fig. 2. The procedure of lung ultrasonography. The patient was examined in the supine position, with the probe being placed on the bedside lung ultrasound in emergency point, especially on the anterior chest, to confirm the ultrasound findings.

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  Fig. 3. An integrated assessment of Type 2 negative-pressure pulmonary edema, presenting as diffuse alveolar hemorrhage, using lung ultrasound (A, B), chest radiograph (C), and high–resolution computed tomography (HRCT) (D) with schematic representations (E–H). The infiltrative opacification pattern observed in the mid-zone on the chest radiograph (C) and the extensive ground-glass opacities and consolidations seen on the HRCT (D) corresponds to multiple B-lines (A, E) and irregular pleural line with subpleural consolidation (B, F) detected on lung ultrasound. The detailed examination of the lung ultrasound scan is represented by the blue box (G) and blue circle (H), with the convex probe (A, E) and linear probe (B, F) placed longitudinally.

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  Fig. 4. (A) Diffuse alveolar hemorrhage (DAH) in bronchoalveolar lavage (BAL), at trachea (B) DAH in BAL, at carina (C) DAH in BAL at the lingual region of the left upper lobe (D) The progressive hemorrhagic BAL in the serial samples (number 1 is the first BAL, number 2 is the second BAL, and number 3 is the third BAL).

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