Post-extubation Acute Pulmonary Oedema in an Adolescent

Background: Post-extubation Acute Pulmonary Oedema (PEAPO) occurs in 0.1% of patients undergoing general anaesthesia, mostly in healthy children and young individuals, usually immediately after tracheal extubation. In paediatric age it has been rarely described, but the actual incidence is thought to be underestimated as many cases of post-operative respiratory distress may be misdiagnosed.

Case report: A former healthy 15-year-old male was admitted to the emergency department with symptoms and physical examination compatible with acute appendicitis. A laparoscopic appendectomy was performed under general anaesthesia. Immediately after extubation, during which neither aspiration nor vomit were observed, he developed hypoxaemia (SpO₂ 82%), intense coughing and polypnea, requiring additional O₂ (FiO₂ 40% using Venturi mask). He was hemodynamically stable, with normal cardiac auscultation and without oedema. His thorax expansion was symmetrical, and pulmonary auscultation presented symmetrical decreased breath sounds with dispersed fine crackles. Arterial gasometry showed pH 7.36, pCO₂ 45mmHg, pO₂ 48mmHg, HCO₃^- 26.8mmol/L, BE -0.5mmol/L, and the chest radiograph revealed bilateral diffuse opacities with ill-defined edges, suggesting acute pulmonary oedema. Intravenous furosemide was administered, and a quick recovery was noticed. The drug was maintained during 3 days, as well as supplementary oxygen, with progressive decreasing. With favourable evolution, the patient was discharged 4 days after surgery, asymptomatic, with normal cardiac evaluation and chest radiograph.

Conclusion: Although rare, PEAPO is a potentially fatal complication, which may worsen the prognosis of low-risk surgical procedures. It is important to recall this diagnosis in children and adolescents who present signs of respiratory distress and hypoxia after general anaesthesia, as prompt intervention is essential for a favourable outcome.