Postoperative pulmonary edema in young,athletic adults

Abstract

Pulmonary edema secondary to postextubation laryn gospasm is a potentially life-threatening problem, de manding early diagnosis and prompt treatment. We believe that this problem has been grossly underesti mated in its incidence, as only seven adults have been reported in the English literature, whereas seven adults have been observed at our institution in only a 24 month period. All were young, healthy, athletic adult males (average weight, 218 pounds) who underwent relatively minor, uncomplicated surgical procedures under gen eral anesthesia.

Five of these patients were collegiate and/or profes sional athletes and had meticulous medical records detailing their clinical course. Clinical laryngospasm was noted immediately following extubation and anesthesia by mask with subsequent pulmonary edema. The di agnoses were confirmed by clinical examination, arterial blood gas determinations or pulse oximetry, and chest roentgenogram. Four adults required reintubation. Six of the seven adults demonstrated very rapid resolution of the pulmonary edema with prompt diagnosis and institution of a therapeutic regimen including oxygen, diuretics, reintubation, and/or positive pressure venti lation. In one patient, the problem was not immediately recognized, and progressed to florid pulmonary edema requiring emergent intubation 14 hours later in the emergency room, and 3 days of mechanical ventilation.

The etiology of pulmonary edema following upper airway obstruction represents an interplay between several factors: cardiogenic and neurogenic mecha nisms, as well as hypoxia contribute. In this group, excessive negative intrathoracic pressure generated by forced inspiration against a closed glottis is the most likely, consistent, and logical explanation.

This study suggests that young, healthy, athletic males may be at increased risk for this complication. We believe that their enhanced ability to generate ex cessive negative intrathoracic pressures is, at least in part, responsible. A heightened awareness of the prob lem in this at-risk group should invoke special consid erations, including choice of anesthesia, precautions on extubation, prolonged monitoring in the recovery phase if laryngospasm is observed or suspected, and rapid therapeutic intervention.

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References

Barash PG, Cullen BF, Stoelting RK (Eds): Climcal Anesthesia JB Lippincott, Philadelphia, 1989, p 556

Buda AJ, Pinsky MB, Ingels NB, et al The effect of intrathoracic pressure on left ventricular performance N Engl J Med 301 453-459, 1979

Cass N. Pulmonary edema due to respiratory obstruction. Anesth Intens Care 9 78-79, 1981

Cayler GG, Johnson EE, Lewis BE, et al: Heart failure due to enlarged tonsils and adenoids The Cardiorespiratory Syndrome of Increased Airway Resistence Am J Dis Child 118 708-717, 1965

Cook CD, Mead J. Maximum and minimum airway pressures at various lung volumes in normal children and adults Fed Proc 19 377, 1960

Cozanitis DA , Leijala M., Pesonen E., et al. Acute pulmonary edema due to laryngospasm Anesthesia 37 1198-1199, 1982

Frank LP, Schreiber GC Pulmonary edema following acute upper airway obstruction Anesthesia 65 106, 1986

Galvis AG, Stool SE, Bluestone CD Pulmonary edema following relief of acute upper airway obstruction . Ann Otol 89 124-128, 1980

Gefke K., Andersen W., Friesel E. Lidocaine given intravenously as a suppressant of cough and laryngospasm in connection with extubation after tonsillectomy ACTA Anesth Scand 27. 111-112, 1983

10.

Haddy FJ, Campbell GS, Visscher MB Pulmonary vascular pressures in relation to edema production by airway resistance and plethora in dogs Am J Physiol 161 336-341, 1950

11.

Hultgren HN, Lopez CE, Lundberg E., et al Physiologic studies of pulmonary edema at high altitudes. Circulation 29. 393-408, 1964

12.

Humphreys RL , Berne AS Rapid re-expansion of pneumothorax A cause of unilateral pulmonary edema Radiology 96. 509-512, 1970

13.

Hurley RM, Kearns JR Pulmonary edema and croup Pediatrics 65 860, 1980

14.

Jackson FN, Rowland V., Corssen G.: Laryngospasm-induced pulmonary edema. Chest 78. 819-821, 1980

15.

Kamal RS, Agha S. Acute pulmonary edema A complication of upper airway obstruction Anaesthesia 39: 464-467, 1984

16.

Kanter RK, Watchko JF Pulmonary edema associated with upper airway obstruction. Am J Dis Child 138 356-358, 1984

17.

Lee Kwt, Downes JJ Pulmonary edema secondary to laryngospasm in children Anesthesia 59. 347-349, 1983

18.

Leicht P., Wisborg T., Chraemmer-Jorgen B. Does intravenous lidocaine prevent laryngospasm after extubation in children . Anesth Analg 64: 1193-1196,1985

19.

Lorch DG, Sahn SA Post extubation pulmonary edema following anesthesia induced by upper airway obstruction. Are certain patients at increased risk7 Chest 90. 802-805, 1986

20.

Mahajak VK, Simon M., Huber GL: Re-expansion pulmonary edema. Chest 75.192-194, 1979

21.

McGonagle M. , Kennedy T. Laryngospasm induced pulmonary edema Laryngoscope 94. 1583-1585, 1984

22.

Melnick BM Postlaryngospasm pulmonary edema in adults anesthesia Anesthesiology 60. 516-517, 1984

23.

Miller RD (Ed ). Anesthesia Volume 1. New York, Churchill Livingstone, 1986 , p 545

24.

Moon RE, Camporesi E. Pulmonary edema in a young healthy woman Chest 92: 385-386, 1987

25.

Moss G., Staunton C., Stein A. The centrineurogenic etiology of the acute respiratory distress syndrome Am J Surg 126 37-41, 1973

26.

Newton-John H. Pulmonary oedema in upper airway obstruction Lancet 2 (8036) 510, 1977

27.

Olsson GL, Hallen B. Laryngospasm during anesthesia—a computer-aided study in 136,929 patients ACTA Anesthesiol Scand 28 567-575, 1984

28.

Oswalt CE, Gates GA, Holmstrom F. Pulmonary edema as a complication of acute airway obstruction JAMA 238 1833-1835, 1977

29.

Robotham JL , Lixfeld W., Holland L., et al Effects of respiration on cardiac performance J Applied Physiol 44 703-709, 1978

30.

Sabiston DC, Spencer FC (Eds) Gibbons Surgery of the Chest Philadelphia , WB Saunders Co 1983, p 363

31.

Smith-Erichsen N., Bo G. Airway closure and fluid filtration in the lung Br J Anesth 51 475-479, 1979

32.

Sofer S., Bar-Ziv J., Scharf SM Pulmonary edema following relief of upper airway obstruction Chest 86 401-403, 1984

33.

Soliman MG, Richer P. Epigiottitis and pulmonary edema in children Can Anaesth Soc J 25 270-275, 1978

34.

Stalcup A., Mellins RB Mechanical forces producing pulmonary edema In acute asthma New Engl J Med 297 592-596, 1977

35.

Stradling JR , Bolton P. Upper airways obstruction as the cause of pulmonary oedema. Lancet 1 (8285) 1353-1354, 1982

36.

Tami TA, Chu F., Wildes TO, et al Pulmonary edema and acute upper airway obstruction Laryngoscope 96 506-509, 1986

37.

Theodore J. , Robin ED Pathogenesis of neurogenic pulmonary edema . Lancet 749-751, 1975

38.

Travis KW, Todres ID, Shannon DC Pulmonary edema associated with croup and epiglottitis Pediatrics 59 695-698, 1977

39.

Wallace O, Rahn H (Ed) Respiration, in Handbook on Physiology, Baltimore, Williams & Wilkins, 1965, p 404

40.

Weissman C. , Damask MC, Yang J. Non-cardiogenic pulmonary edema following laryngeal obstruction Anesthesia 60. 163-165, 1984