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Your next patient on the orthopedic wait list is a 26-year-old man scheduled to have an intramedullary tibial nail open reduction internal fixation (ORIF) after colliding with two other players playing recreational hockey 36 hours ago. His past medical history includes a 5 pack-year history of smoking. As for his past surgical history, he underwent an anterior cruciate ligament (ACL) repair two years ago secondary to a football injury. His only medication consists of subcutaneous hydromorphone on the floor for pain. Laboratory investigations are normal. He weighs 220 lbs (100 kg) and is 6′0″ (183 cm) tall; body mass index (BMI) is 29.9 kg·m−2. Preoperative airway examination reveals normal mouth opening with full set of teeth, a thyromental span of 4 cm, and good jaw protrusion. He demonstrates a modified Mallampati score of II and has a normal cervical range of motion. The rest of his physical examination is unremarkable. He has been fasting since midnight.

Following appropriate positioning and denitrogenation, the induction is performed using midazolam, fentanyl, propofol, and rocuronium. Direct laryngoscopy using a Macintosh #4 blade reveals a Cormack-Lehane (C-L)1 Grade 2 view. The trachea is successfully intubated using an 8.0-mm internal diameter (ID) endotracheal tube (ETT). General anesthesia is maintained with sevoflurane. After the airway is secured, three stacks of gauze are rolled up and inserted into the mouth as a bite block. Over the course of the case, several doses of hydromorphone are given for analgesia. Additional doses of rocuronium are also given for muscle relaxation. Two and a half liters of Ringer’s lactate are given during the 2-hour procedure. On emergence, residual neuromuscular blockade is fully reversed.

At this time, the patient starts to cough and buck on the ventilator. He then proceeds to spit out the gauze bite block and subsequently bites down on the ETT. For a period of approximately 60 seconds, no gas exchange occurs, even with attempted assisted manual ventilation via the anesthetic circuit. Although respiratory efforts continue, no CO2 trace is apparent during the episode. Oxygen saturation falls to 78% before his jaw relaxes somewhat, allowing assisted, then spontaneous ventilation to resume. At this point, the patient is extubated. Shortly after extubation, he begins 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 postextubation, drops to 85%.


What Is Postobstructive Pulmonary Edema (POPE)?

Postobstructive pulmonary edema (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 the obstruction has been relieved, treatment of POPE is ...

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