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A 26-year-old man presented with a fractured tibia and fibula, sustained during a collision with two other players while playing recreational hockey. He was scheduled for open reduction and internal fixation of the fractures. Significant past medical history was limited to a 5 pack-year history of smoking. He had previously undergone reconstruction of an anterior cruciate ligament without incident. He was on no medications pre-morbidly and laboratory investigations were normal. He weighed 220 lb (100 kg) and was 6′0″ (183 cm) tall. Preoperative airway examination revealed normal mouth opening with full teeth, a thyromental span of 4 cm, and good jaw protrusion. He demonstrated a modified Mallampati score1 of II and had a normal cervical range of motion. The rest of his physical examination was unremarkable. He had been fasted for 8 hours preoperatively.

Following appropriate positioning and denitrogenation, general anesthesia was induced using midazolam, fentanyl, and propofol. Rocuronium was administered to facilitate tracheal intubation. Direct laryngoscopy using a Macintosh #4 blade revealed a Cormack–Lehane (C/L)2 Grade 2 view, and successful tracheal intubation using an 8.0-mm internal diameter (ID) endotracheal tube (ETT) followed. General anesthesia was maintained with sevoflurane in air and oxygen. After the airway was secured, three 4 × 8 inch gauze flats were rolled up and inserted into the mouth as a bite block. Over the course of the 2-hour case, several doses of hydromorphone were given for analgesia. Additional doses of rocuronium were also given for muscle relaxation, with monitoring by a nerve stimulator. Two liters of Ringer's lactate were given during the procedure. Estimated blood loss was 150 mL. On emergence, residual neuromuscular blockade was fully reversed.

At this time, the patient started to cough and buck on the ventilator. He then proceeded to spit out the gauze bite block and subsequently bit down on the ETT. For a period of approximately 60 seconds, no gas exchange occurred, even with attempted assisted manual ventilation via the anesthetic circuit. Although respiratory efforts continued, no CO2 trace was apparent during the episode. Oxygen saturation fell to 78% before his jaw relaxed somewhat, allowing assisted, then spontaneous ventilation to resume. Once conscious, with his oxygen saturation recovered to >90% and a regular pattern of respiration, the patient was extubated. Shortly after extubation, he began to cough up frothy, pink fluid without either retching or vomiting. His oxygen saturation, which had been 97% on a simple oxygen face mask immediately after extubation, dropped to 85%.


What Is Post-Obstructive Pulmonary Edema (POPE)?

POPE is characterized by the sudden onset of pulmonary edema of varying severity following vigorous inspiratory efforts against an obstructed upper airway. It most often occurs in a patient with no intrinsic cardiac, neurologic, or pulmonary disease. POPE usually presents with dyspnea, tachypnea, hypoxemia and a cough productive of pink, frothy sputum. After confirming that ...

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