Avoidance of Pulmonary Edema

Aaron I. Cohn, M.D.

To the Editor:

Just Wake ‘Em Up! I read Dr. Ohn’s case report1 with interest and had a few comments. First, I think negative pressure pulmonary edema may not be very rare; Galvis, et al.2, reported five cases within one year. We have had three cases in our institution the past year. The usual etiology in our institution is premature extubation at case conclusion with consequent laryngospasm and airway obstruction. Second, a detailed report concerning physical examination of the airway would be important in this article. If anatomic features had predicted difficult endotracheal intubation, an awake intubation may be pursued by many practitioners. For that matter, some practitioners routinely intubate patients awake.3 While that approach is idiosyncratic, it is difficult to criticize, since half of difficult intubations are unanticipated. Finally, once difficulty had been encountered, I wondered whether the author considered awakening the patient and pursuing awake intubation or even returning another day to pursue awake fiberoptic, Bullard3,4,5 or retrograde techniques. Though the indications for awake endotracheal intubation are nebulous, given a scenario of multiple failed laryngoscopies and a tenuous mask airway, most reasonable risk-benefit analyses would strongly favor awake intubation. Endotracheal intubation under awake sedation is often rather benign and well-tolerated. Those rare patients who remember the procedure generally accept it when the underlying rationale is adequately explained. With practice, awake endotracheal intubation can be performed rapidly in even the most time-pressured circumstances.5

Aaron I. Cohn, M.D. Assistant Professor Department of Anesthesiology The University of Texas Medical Branch at Galveston Galveston, TX


  1. Ohn JKC. Non-cardiogenic pulmonary edema after difficult intubation. APSF Newsletter 1995; 10:22-23.
  2. Galvis AG, Stool SE, Bluestone CD. Pulmonary edema following relief of acute upper airway obstruction. Ann Oto 1980;89: 124-128.
  3. Neubarth J. Five minutes for life. Educational synopses in anesthesiology and critical care medicine. 2(1); January 1995 (an on-line journal available by e-mail from Keith Ruskin, M.D., at NYU: Internet: esia@mcan15.med.nyu.edu).
  4. Cohn Al, McGraw SR, King WH. Awake intubation of the adult trachea using the bullard laryngoscope. Can J Anaesth 1995;42:246-248.
  5. Cohn Al, Hart RT, McGraw SR, Blass NH. The Bullard laryngoscope for emergency airway manage- ment in a morbidly obese parturient. Anesth Analg 1995;81:872-873.