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.