BACKGROUND Unilateral pulmonary hemorrhage is typically reported in young and healthy men with upper respiratory tract obstruction during anesthesia in special situations. Negative pressure in the lungs is created, resulting in negative pressure pulmonary edema (NPPE). CASE SUMMARY A 78-year-old male patient diagnosed with spinal stenosis was admitted to receive a unilateral laminectomy with bilateral decompression. The patient had been diagnosed with hypertension four years earlier and asthma more than 70 years earlier. We experienced a unilateral alveolar hemorrhage associated with NPPE that occurred in a longstanding asthma patient who bit the intubated endotracheal tube for a short period during posture change at the end of surgery. Because diffuse alveolar hemorrhage accompanied by NPPE was caused in this case by airway obstruction in an older patient with asthma without known risk factors, anesthesiologists should be careful not to induce airway irritation during anesthesia awakening in asthma patients. CONCLUSION Because diffuse alveolar hemorrhage accompanied by NPPE can occur, anesthesiologists should take care not to induce airway irritation.