November FY24

[kristenhorsman]

The November journal club is presented by Anne McNulty. She chose a current review about postobstructive pumonary edema (POPE). Please refer to the article that is attached to the email I sent out. Please answer the following two questions:

1. What are the two types of POPE? Etiology?
2. What is the clinical picture of POPE? Have you ever used the Muller Maneuver?

[Jessica Hadley]

There are two subclasses of POPE. Type 1 caused by inspiratory effort against an acute airway obstruction and type 2 resulting from relief of a partial chronic obstruction.

The typical clinical picture of POPE typically presents as pink frothy sputum as a result of interstitial edema. Xray demonstrating alveolar and interstitial edema confirms the diagnosis. I have never intentionally used the muller manuever. I have had one case of POPE, the patient was a young, obese women who upon emergence woke up fighting. We elected to extubate and she proceeded to laryngospasm. With a jaw thrust and positive pressure her laryngospasm broke, however almost immediately she began coughing up pink frothy sputum. She was able to maintain her SPO2 with a mask and was taken to PACU. She had an xray there which showed POPE. She did not require further intervention, but she did require extra monitoring.

[Ben Waldbaum]

Type 1: Inspiration in the presence of an acute airway obstruction. Patient who are young and muscular are at the highest risk. Most common cause is laryngospasm. In children common causes are croup and epiglotitis.
Type 2: Expiration in the presence of the relief of chronic partial airway obstruction. This can be caused by adenoidectomy, layrngeal surgery, or choanal stenosis
The most common clinical picture is pulmonary edema which resolves within 24-48 hours with no long term complications. During the acute pulmonary edema gas exchange can be affected and result in hypoxia. Patient may produce pink frothy sputum, respiratory distress, tachypnea, and bilateral rales.
The Muller maneuver can cause POPE and I am not aware of any reason an anesthesia provider would do it. It can be used in the clinic by non-anesthesia clinicians to identify the source of obstruction in OSA to guide treatment. But again, POPE can result from that maneuver.

[sjsimmons]

1. There are 2 types of negative pressure pulmonary edema (aka POPE), type 1 involves inspiratory effort against an acute airway obstruction, most commonly with post-extubation laryngospasm, while type 2 involves sudden surgical relief in chronic partial obstruction.

2. POPE presents as an immediate onset of respiratory distress in the setting of acute airway obstruction, followed by acute dyspnea, tachypnea, agitation, cough, and bilateral pulmonary rales. In addition to hypoxemia, the patient may develop tachycardia and hypertension. Stridor is specific to patients with type 1 POPE. The development of pink, frothy sputum is a key sign of POPE and chest xrays demonstrate the rapid formation of alveolar and interstitial edema. I have never used the Muller maneuver, as this could cause POPE, but I have used techniques such as a jaw thrust, positive pressure & propofol to break a laryngospasm that (I believe) led to POPE.

[kels]

1. What are the two types of POPE? Etiology?

Type 1: inspiratory effort against an acute airway obstruction such as laryngospasm

Type 2: acute surgical relief in a chronic partial obstruction such as airway surgery


2. What is the clinical picture of POPE? SOB / Hypoxia/ pink frothy sputum

Have you ever used the Muller Maneuver? NO

[aileenm4]

POPE type 1 is cause by inspiration against a closed glottis, as from laryngospasm, croup, strangulation
POPE type 2 is caused by relief of a chronic obstruction as in OSA, goiter, adenoid or tonsilar hypertrophy

clinical picture is resp distress, dyspnea, increased resp rate, agitation, cough, bilat rales, desats, hypoxia, pink frothy sputum, xray with patchy pulm infiltrates at perihilar area.

the Muller manuever is the reversal of a valsalva, I do not see it used routinely, in the past we used to use a NIF to assess extubation criteria, the [atient needed to have a minimum of -20 CM H2O for effective cough to clear their secretions of their VC, in a healthy muscular man they could generate a NIF of -100 to -140, thus my only case of POPE was on a very muscular young male post extubation.

[Amy Swank]

1. Two types of POPE etiology: type 1 caused by an inspiratory effort against an acute airway obstruction.
Most common etiology is laryngospasm, frequently seen in young, muscular patients who can generate the significant negative intrathoracic pressures needed to alter the involved physiology. With a higher incidence in ASA class 1 or 2 males.
Type 2 resulting from chronic partial obstruction relief - often seen following ENT surgeries.
Clinical Signs of POPE include:
Acute respiratory distress - tachypnea, dyspnea, stridor.
Resultant hypoxemia.
Frothy pink sputum, possible frank hemoptysis.
Bilateral rales on auscultation
CXR with patchy pulmonary interstitial infiltrates, perihilar regions.
Normal ECHO

2. I have not "used" the Muller Maneuver however, I have seen a couple of young strong healthy males forcefully inspire against an obstructed glottis - generating a significant negative intrathoracic pressure known as the Muller maneuver.

[Tracey Trainum]

1. Type 1: Inspiratory effort against and acute airway obstruction. Type 2: Occurs when there is relief of a partial obstruction
2. Clinical picture: Acute onset of respiratory distress in the setting of acute airway obstruction. Signs include dyspnea, tachypnea, agitation, cough, and bilateral pulmonary rales. Paradoxical breathing can develop with rapid progression to desaturataion, tachycardia, and hypotension. Stridor is a specific sign of type I POPE. Classic sign is pink frothy sputum secondary to insterstitial edema. Chest xrays will show rapid signs of alveolar and insterstitial edema with alveolar edema being seen as airspace consolidation and insterstitial edema as perihilar congestion. Perivascular cuffing and Kerley lines can also be seen on xray.

The Muller maneuver is defined as forced inspiration against a closed glottis and this process could cause POPE. The Muller maneuver in a clinical setting can help evaluate the degree of upper airway narrowing and obstruction.

[Soo-Ok Kim]

1. What are the two types of POPE? Etiology?

2 types: Type 1: Inspiratory effort against and acute airway obstruction. Type 2: Occurs when there is relief of a partial obstruction.

2. What is the clinical picture of POPE? Have you ever used the Muller Maneuver?
SOB, Hypoxia and pink frothy sputum.
I have not used Muller maneuver.