Negative-pressure pulmonary edema after upper airway obstruction during transesophageal echocardiogram

Published:November 16, 2022DOI:


      Negative-pressure pulmonary edema (NPPE) has become a well-recognized, though uncommon, complication of acute upper airway obstruction. While initially described in the setting of peri-operative endotracheal intubation, NPPE has been increasingly observed in numerous other clinical scenarios. In this report, we describe a case of NPPE that occurred after a scheduled cardioversion and transesophageal echocardiogram (TEE). We suspect the attempt at TEE probe placement inadvertently led to tracheal insertion as suggested by excessive resistance, poor visualization, stridor, and subsequent acute pulmonary edema. While supportive treatment when recognized can lead to rapid improvement, it is important to recognize NPPE as a possible complication of this commonly indicated procedure.

      Learning objective

      Excessive resistance is a common challenge during the transesophageal echocardiogram (TEE) procedure and may be the result of incidental tracheal insertion. Negative-pressure pulmonary edema (NPPE) may result from this acute upper airway obstruction. Thus, NPPE should be on the differential for patients who present with unexplained non-cardiogenic pulmonary edema and should be recognized as a possible complication of the TEE procedure.


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        • Miller H.G.
        Negative pressure pulmonary edema.
        Can Oper Room Nurs J. 1995; 13: 28-30
        • Watanabe Y.
        • Nagata H.
        • Ichige H.
        • Kojima M.
        Negative pressure pulmonary edema related with severe sleep apnea syndrome: a case report.
        Respir Med Case Rep. 2020; 31: 101153
        • Bhattacharya M.
        • Kallet R.H.
        • Ware L.B.
        • Matthay M.A.
        Negative-pressure pulmonary edema.
        Chest. 2016; 150: 927-933
        • Willms D.
        • Shure D.
        Pulmonary edema due to upper airway obstruction in adults.
        Chest. 1988; 94: 1090-1092
        • Louis P.J.
        • Fernandes R.
        Negative pressure pulmonary edema.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002; 93: 4-6
        • Harmon E.
        • Estrada S.
        • Koene R.J.
        • Mazimba S.
        • Kwon Y.
        Concurrent negative-pressure pulmonary edema (NPPE) and takotsubo syndrome (TTS) after upper airway obstruction.
        Case Rep Cardiol. 2019; 2019: 1-4
        • Hillenbrand K.D.
        • Racine C.L.
        • McNeil J.S.
        • Kleiman A.M.
        Difficult TEE probe placement: the evidence, troubleshooting techniques, and a guide to alternative monitoring options for intraoperative physicians.
        Semin Cardiothorac Vasc Anesth. 2019; 23: 369-378
        • Mathur S.K.
        • Singh P.
        Transoesophageal echocardiography related complications.
        Indian J Anaesth. 2009; 53: 567-574