Canadian Journal of Anaesthesia

, Volume 37, Issue 2, pp 210–218 | Cite as

Pulmonary oedema associated with airway obstruction

  • Scott A. Lang
  • Peter G. Duncan
  • David A. E. Shephard
  • Hung C. Ha
Review Articles


The purpose of this review is to describe the pathogenesis of pulmonary oedema associated with upper airway obstruction, summarize what is known of its clinical presentation, and reflect upon its implications for the clinical management of airway obstruction. The pathogenesis of pulmonary oedema associated with upper airway obstruction is multifactorial. However, as the phrase “negative pressure pulmonary oedema” suggests, markedly negative intrapleural pressure is the dominant pathophysiological mechanism involved in the genesis of pulmonary oedema associated with upper airway obstruction. The frequency of the event is impossible to ascertain from the literature but paediatric cases requiring airway intervention for croup or epiglottitis and adults requiring airway intervention for emergence laryngospasm or upper airway tumours account for over 50 per cent of the documented cases in each age group, respectively. Individuals at risk should be observed closely while they remain at risk. The majority of cases present within minutes either of the development of acute severe upper airway obstruction or of relief of the obstruction. Resolution is typically rapid, over a period of a few hours. Rarely is anything more required for management than the maintenance of a patent airway, supplemental oxygen, and, in approximately 50 per cent of cases, mechanical ventilation and positive end-expiratory pressure.

Key words

airway: obstruction complications: oedema, pulmonary larynx: spasm lung: oedema 


Dans cet article, nous décrivons la pathogénése de l’oedème pulmonaire associé à l’obstruction de la partie supérieure des voies respiratoires. Nous en revoyons les aspects cliniques et, en analysons l’importance sur l’attitude à prendre devant une obstruction des voies aériennes. Les mécanismes sous-jacentes à ce type d’oedème pulmonaire sont multiples, le principal demeurant toutefois la présence de pressions intrapleurales « très » négatives. L’incidence du phénomène demeure difficile à évaluer mais il semble bien que chez les enfants, près de 50 pour cent des épisodes se produisent dans des cas de laryngite ou d’épiglottite nécessitant une intubation tandis que chez les adultes, on en retrouve une proportion semblable associée aux laryngospasmes survenant à l’émergence de l’anesthésie ou dans les cas de tumeurs situées haut dans les voies aériennes. Une fois identifiées, les victimes potentielles devraient être observées de près tant que le risque persiste même si ce sont les premières minutes qui suivent le développement ou la résolution d’une obstruction aiguë qui sont les plus critiques. Ce type d’œdème pulmonaire est transitoire, s’estompant en quelques heures. S’il survient, on doit s’assurer de la perméabilité des voies aériennes et faire respirer de l’oxygène quoique dans près de la moitié des cas, la ventilation mécanique avec pression positive en fin d’expiration s’avérera nécessaire.


  1. 1.
    Moore RL. The response to respiratory resistance: a comparison of the effects produced by partial obstruction in the inspiratory and expiratory phases of respiration. J Exp Med 1927; 45: 1065–80.CrossRefPubMedGoogle Scholar
  2. 2.
    Warren MF, Peterson DK, Drinker CK. The effects of heightened negative pressure in the chest, together with further experiments upon anoxia in increasing the flow of lung lymph. Am J Physiol 1942; 137: 641–8.Google Scholar
  3. 3.
    Capitanio MA, Kirkpatrick JA. Obstructions of the upper airway in children as reflected on the chest radiograph. Ped Radiol 1973; 107: 159–61.Google Scholar
  4. 4.
    Oswalt CE, Gater GA, Holmstrom FMG. Pulmonary edema as a complication of acute airway obstruction. JAMA 1977; 238: 1833–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Kanter RK, Watchko JF. Pulmonary edema associated with upper airway obstruction. Am J Dis Child 1984; 128: 356–8.Google Scholar
  6. 6.
    Tami TA, Cu F, Welcles TO, Kaplan M. Pulmonary edema and acute upper airway obstruction. Laryngoscope 1986; 86: 506–9.CrossRefGoogle Scholar
  7. 7.
    Starling EH. On the absorption of fluids from the connective tissue spaces. J Physiol 1986; 19: 312–26.Google Scholar
  8. 8.
    Allen SJ, Drake RE, Williams JB, Laine GA, Gabel JC. Recent advances in pulmonary edema. Crit Care Med 1987; 15: 963–70.PubMedGoogle Scholar
  9. 9.
    Wise RA. Effect of circulatory mechanics on hydrostatic forces producing pulmonary edema. J Crit Care 1986; 1: 247–56.CrossRefGoogle Scholar
  10. 10.
    Lorch DG, Sahn SA. Post-extubation pulmonary edema following anesthesia induced by upper airway obstruction. Chest 1986; 90: 802–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Price SL, Hecker BR. Pulmonary oedema following airway obstruction in a patient with Hodgkin’s disease. Br J Anaesth 1987; 59: 518–21.PubMedCrossRefGoogle Scholar
  12. 12.
    Buda AJ, Pinsky MR, Ingels NB, Daughters GT, Stinson EB, Alderman EL. Effect of intrathoracic pressure on left ventricular performance. N Engl J Med 1979; 301: 453–9.PubMedGoogle Scholar
  13. 13.
    Brower R, Wise RA, Hassapayannes C, Brombuger-Barnes B, Permutt S. Effect of lung inflation on lung blood volumes and pulmonary venous flow. J Appl Physiol 1985; 58: 954–63.PubMedCrossRefGoogle Scholar
  14. 14.
    Peters J, Kindred MK, Robotham JL. Transient analysis of cardiopulmonary interactions I. Diastolic events. J Appl Physiol 1988; 64: 1506–17.PubMedGoogle Scholar
  15. 15.
    Peters J, Kindred MK, Robotham JL. Transient analysis of cardiopulmonary interactions II. Systolic events. J Appl Physiol 1988; 64: 1518–26.PubMedGoogle Scholar
  16. 16.
    Robotham JL, Stuart RS, Doberty K, Borkon AM, Baumgartner W. Mitral and aortic blood flows during spontaneous respiration in dogs. Anesthesiology 1988; 69: 516–26.PubMedCrossRefGoogle Scholar
  17. 17.
    Stalcup SA, Mellins RB. Mechanical forces producing pulmonary edema in acute asthma. N Engl J Med 1977; 297: 592–6.PubMedGoogle Scholar
  18. 18.
    Newton-John H. Pulmonary oedema in upper airway obstruction. Lancet 1977; 2: 510.PubMedCrossRefGoogle Scholar
  19. 19.
    Smith-Erichsen N, Bo G. Airway closure and fluid filtration in the lung. Br J Anaesth 1979; 51: 475–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Lloyd JE, Nolop KB, Parker RE, Roselli RJ, Brigham KL. Effects of inspiratory resistance loading on lung fluid balance in awake sheep. J Appl Physiol 1986; 60: 198–203.Google Scholar
  21. 21.
    West JB. Respiratory Physiology — The Essentials. 3rd ed, Baltimore, Williams and Wilkins 1985; 40–3.Google Scholar
  22. 22.
    Engeberg J andDubois AB. Mechanics of pulmonary circulation in isolated rabbit lungs. Am J Physiol 1959; 196: 401–14.Google Scholar
  23. 23.
    Sarnoff SJ, Berglund E, Sarnojf LC. Neurohemodynamics of pulmonary edema III. Estimated changes in pulmonary blood volume accompanying systemic vasoconstriction and vasodilatation. J Appl Physiol 1953; 5: 367–74.PubMedGoogle Scholar
  24. 24.
    Miller WC, Toon R, Ralat H, Lacroix J. Experimental pulmonary edema following re-expansion of pneumothorax. Am Rev Respir Dis 1973; 108: 664–6.Google Scholar
  25. 25.
    Schoene RB, Swenson ER, Pizzo CJ et al. The lung at high altitude: bronchoalveolar lavage in acute mountain sickness and pulmonary edema. J Appl Physiol 1988; 64: 2605–13.PubMedGoogle Scholar
  26. 26.
    Viswanathan R, Subramanian S, Radha TG. Effect of hypoxia on regional perfusion by scanning. Respiration 1979; 37: 142–7.PubMedGoogle Scholar
  27. 27.
    Schoene RB. Pulmonary edema at high attitude: review, pathophysiology and update. Clin Chest Med 1985; 6: 491–507.PubMedGoogle Scholar
  28. 28.
    Maunder RJ, Shuman WP, McHugh JW, Marglin SI, Butler J. Preservation of normal lung regions in the adult respiratory distress syndrome. Analysis by computed tomography. JAMA 1986; 255: 2463–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Kabayashi T, Kajama S, Kubo K, Fukushima M, Kusama S. Clinical features of patients with high-altitude pulmonary edema in Japan. Chest 1987; 92: 814–21.CrossRefGoogle Scholar
  30. 30.
    Maron MB, Dawson CA. Pulmonary venoconstriction caused by elevated cerebrospinal fluid pressure in the dog. J Appl Physiol 1980; 49: 73–8.PubMedGoogle Scholar
  31. 31.
    Moss G, Stanton C, Stein AA. The centrineurogenic etiology of acute respiratory distress syndrome. Am J Surg 1973; 126: 39–41.Google Scholar
  32. 32.
    Sarnoff SJ, Sarnoff LC. Neurohemodynamics of pulmonary edema II. The role of sympathetic pathways in the elevation of pulmonary and systemic vascular pressures following the intracisternal injection of fibrin. Circulation 1952; 6: 51–62.PubMedGoogle Scholar
  33. 33.
    Colice GL, Matthay MA, Bass E, Matthay RA. Neurogenic pulmonary edema. Am Rev Resp Dis 1984; 130: 941–8.PubMedGoogle Scholar
  34. 34.
    Sarnoff SJ, Sarnoff LC. Neurohemodynamics of pulmonary edema I. Autonomic influence on pulmonary vascular pressures and the acute pulmonary edema state. Dis Chest 1952; 22: 685.PubMedGoogle Scholar
  35. 35.
    MacKay EM. Experimental pulmonary edema. IV. Pulmonary edema accompanying trauma to the brain. Proc Soc Exp Biol Med 1950; 74: 695–7.PubMedGoogle Scholar
  36. 36.
    Sarnoff SJ, Bergland E. Neurohemodynamics of pulmonary edema IV. Effects of systemic vasoconstriction and subsequent vasodilatation on flow and pressure of systemic and pulmonary vascular beds. Am J Physiol 1952; 170: 588–600.PubMedGoogle Scholar
  37. 37.
    Theodore J, Robin ED. Speculations on neurogenic pulmonary edema. Am Rev Resp Dis 1976; 113: 405–11.PubMedGoogle Scholar
  38. 38.
    Beckman DL, Ginty DD, Gaither AC. Neurogenic pulmonary edema in a pulmonary normotensive model. Proc Soc Exp Biol Med 1987; 186: 170–3.PubMedGoogle Scholar
  39. 39.
    Nakamura J, Zhang SW, Ishikawa N. Role of pulmonary inncrvation in a canine in situ lung-perfusion preparation: a new model of neurogenic pulmonary edema. Clin Exp Pharmacol Physiol 1987; 14: 535–42.PubMedCrossRefGoogle Scholar
  40. 40.
    Hakim TS, van der Zee H, Malik AB. Effects of sympathetic nerve stimulation on lung fluid and protein exchange. J Appl Physiol 1979; 47: 1025–30.PubMedGoogle Scholar
  41. 41.
    Mitchell RA, Wildenthal K, Johnson RL Jr. The effects of acid-base disturbance on cardiovascular and pulmonary function. Kidney Int 1972; 1: 375–89.PubMedCrossRefGoogle Scholar
  42. 42.
    Glasser SA, Siler JN. Delayed onset of laryngospasminduced pulmonary edema in an adult outpatient. Anesthesiology 1985; 62: 370–1.PubMedCrossRefGoogle Scholar
  43. 43.
    Andersen C, Kancir CB, Nielsen KD. Laryngospasminduced pulmonary edema. Acta Anaesthesiol Scand 1988; 32: 710–1.PubMedGoogle Scholar
  44. 44.
    Galvis AG, Stool SE, Bluestone CD. Pulmonary edema following relief of acute upper airway obstruction. Ann Otol Rhinol Laryngol 1980; 89: 124–8.PubMedGoogle Scholar
  45. 45.
    Mulnick BM. Postlaryngospasm pulmonary edema in adults. Anesthesiology 1984; 60: 516–7.CrossRefGoogle Scholar
  46. 46.
    Sofer S, Bar-Ziv J, Scharf SM. Pulmonary edema following relief of upper airway obstruction. Chest 1984; 86: 401–3.PubMedCrossRefGoogle Scholar
  47. 47.
    Weissman C, Damask MC, Yang J. Noncardiogenic pulmonary edema following laryngeal obstruction. Anesthesiology 1984; 60: 163–5.PubMedCrossRefGoogle Scholar
  48. 48.
    Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-pcep effect. Am Rev Rcspir Dis 1982; 126: 166–70.Google Scholar
  49. 49.
    Scherer R, Dreyer P, Jorch G. Pulmonary edema due to partial upper airway obstruction in a child. Intensive Care Med 198; 14:661–2.Google Scholar
  50. 50.
    Masa-Jimeney JF, Verea-Hernando HR, Domenguey-Juneal L, Fontan-Bueso JM. Pulmonary edema and upper airway obstruction. Chest 1985; 88: 643.CrossRefGoogle Scholar
  51. 51.
    Leatherman JW, Schwarty S. Pulmonary edema due to upper airway obstruction. South Med J 1983; 76: 1058–60.PubMedGoogle Scholar
  52. 52.
    Willms D, Shure D. Pulmonary edema due to upper airway obstruction in adults. Chest 1988; 94: 1090–2.PubMedCrossRefGoogle Scholar
  53. 53.
    Miller RD. Anesthesia. 2nd ed. New York, Churchill Livingston 1986; 2043–5.Google Scholar
  54. 54.
    Travis KW, Todres ID, Shannon DC. Pulmonary edema associated with croup and epiglottitis. Pediatrics 1977; 59: 695–8.PubMedGoogle Scholar
  55. 55.
    Soliman MG, Ricker P. Epiglottitis and pulmonary oedema in children. Can Anaesth Soc J 1978; 25: 270–5.PubMedCrossRefGoogle Scholar
  56. 56.
    Lee KWT, Downes JJ. Pulmonary edema secondary to laryngospasm in children. Anesthesiology 1983; 59: 347–9.PubMedGoogle Scholar
  57. 57.
    Sofer S, Bar-Ziv J, Mogle P. Pulmonary edema following choking: report of two cases. Eur J Pediatr 1985; 143: 295–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Rao CC, McNiece WL, Krishna G. Acute pulmonary edema after removal of an esophagcal foreign body in an infant. Crit Care Med 1986; 14: 988–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Warner LO, Beach TP, Martio JD. Negative pressure pulmonary oedema secondary to airway obstruction in an intubated infant. Can J Anaesth 1988; 35: 507–10.PubMedCrossRefGoogle Scholar
  60. 60.
    Hurley RM, Kearns JR. Pulmonary edema and croup. Pediatrics 1980; 65: 860.PubMedGoogle Scholar
  61. 61.
    Galvis AG. Pulmonary edema complicating relief of upper airway obstruction. Am J Emerg Med 1987; 5: 294–7.PubMedCrossRefGoogle Scholar
  62. 62.
    Rivera M, Hadlock FP, O’Meara ME. Pulmonary edema secondary to acute epiglottitis. Am J Roentg 1979; 132: 991–2.Google Scholar
  63. 63.
    Daron B, Fouron JC. Acute pulmonary edema associated with upper airway obstruction in a newborn infant. Arch Fr Pediatr 1980; 37: 451–4.PubMedGoogle Scholar
  64. 64.
    Jackson FN, Rowland V, Corssen G. Laryngospasminduced pulmonary edema. Chest 1980; 78: 819–21.PubMedCrossRefGoogle Scholar
  65. 65.
    Goldhill DR, Dalgleish JG, Lake RHN. Respiratory problems and cardiomegaly. Anaesthesia 1982; 37: 1200–3.PubMedCrossRefGoogle Scholar
  66. 66.
    Stradling JR, Bolton P. Upper airways obstruction as cause of pulmonary oedema. Lancet 1982; 1: 1353–4.PubMedCrossRefGoogle Scholar
  67. 67.
    Coganitis DA, Leijala M, Personen E, Zaki Ha. Acute pulmonary oedema due to laryngeal spasm. Anaesthesia 1982; 37: 1198–9.CrossRefGoogle Scholar
  68. 68.
    McGonagle M, Kennedy TL. Laryngospasm induced pulmonary edema. Laryngoscope 1984; 94: 1583–5.PubMedCrossRefGoogle Scholar
  69. 69.
    Jenkins JG. Pulmonary edema following laryngospasm. Anesthesiology 1984; 60: 611–2.PubMedCrossRefGoogle Scholar
  70. 70.
    Frank LP, Schreiber GC. Pulmonary edema following acute upper airway obstruction. Anesthesiology 1986; 65: 106.PubMedCrossRefGoogle Scholar
  71. 71.
    Lagler V, Russe E. Upper airway obstruction as a cause of pulmonary edema during late pregnancy. Am J Obstet Gynecol 1987; 156: 643–4.PubMedGoogle Scholar
  72. 72.
    Stead WW. Acute epiglottitis in adults. N Engl J Med 1986; 315: 1163.CrossRefGoogle Scholar
  73. 73.
    Kamal RS, Agha S. Acute pulmonary oedema — a complication of upper airway obstruction. Anaesthesia 1984; 39: 464–7.PubMedCrossRefGoogle Scholar
  74. 74.
    Carr N. Pulmonary oedema due to respiratory obstruction. Anaesth Intensive Care 1981; 9: 78–9.Google Scholar
  75. 75.
    Dash HH, Cherejam AF, Sngla R. Acute fulminating pulmonary edema following relief of airway obstruction. Indian J Chest Dis Allied Sci 1983; 25: 145–8.PubMedGoogle Scholar
  76. 76.
    Batra RK, Jayalaxmi TS, Saksena R, Gode GR. Acute pulmonary edema following an attempted suicidal hanging. Indian J Chest Dis Allied Sci 1984; 26: 272–5.PubMedGoogle Scholar
  77. 77.
    Randour PH, Joucken K, Collard E, Mayne A. Pulmonary edema following acute upper airway obstruction. Acta Anaesthesiol Belg 1986; 37: 225–31.PubMedGoogle Scholar
  78. 78.
    Izsak E. Pulmonary edema due to acute upper airway obstruction from aspirated foreign body. Pediat Emerg Care 1986; 2: 235–7.CrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1990

Authors and Affiliations

  • Scott A. Lang
    • 1
  • Peter G. Duncan
    • 1
  • David A. E. Shephard
    • 1
  • Hung C. Ha
    • 1
  1. 1.Department of AnaesthesiaUniversity HospitalSaskatoon

Personalised recommendations