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

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.