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David J. Krodel, MD; Matthias Eikermann, MD, PhD
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From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School.

Correspondence to: David J. Krodel, MD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114; e-mail: dkrodel@partners.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(5):1365-1366. doi:10.1378/chest.11-3316
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To the Editor:

We thank Dr Medford for his interest in our recent article1 in CHEST and for addressing the important issue of undiagnosed obstructive sleep apnea (OSA) as a potential risk factor for negative pressure pulmonary edema (NPPE). We do not believe that the patient represented a case of unrecognized OSA presenting as NPPE, but rather, as we argued in our original report, a case of bronchospasm resulting in NPPE.

Excess adipose tissue in the oropharyngeal tissues is a key factor in the anatomic development of OSA, yet 30% of patients with OSA are not obese. It is clear that OSA is a risk factor for morbidity in the perioperative period, but the mechanisms are unclear; issues related to airway management seem not to be responsible.2-4 In addition to the risk of upper airway obstruction during sleep and sedation, cyclic hypoxic episodes lead to sympathetic activation and systemic inflammation, as well as perioperative cognitive dysfunction.5 Patients with OSA are more likely to have hypertension, diabetes, heart disease, vascular disease, pulmonary hypertension, and stroke, and these patients frequently have multiple comorbidities that likely add additional risk to the perioperative period.

Case reports have observed pulmonary edema as a presenting symptom of OSA (presumably via the generation of negative intrathoracic pressure during obstructive episodes), although never specifically in the perioperative period.6 The pathophysiology and clinical epidemiology suggest that patients with OSA may be at a higher risk of perioperative NPPE. A recent study of 471 patients undergoing noncardiac surgery who had polysomnography performed in the previous 3 years noted that patients with OSA tended to be older and male and to have higher BMI. NPPE was not specifically identified in this study, but patients with OSA were at a significantly higher risk of postoperative hypoxemia and reintubation,2 which are potential complications of NPPE. The patient was not obese BMI (29 kg/m2), was only in her fifth decade of life, and was female, which put her at a lower risk of unrecognized OSA. Additionally, in the patient, respiratory failure and expiratory stridor persisted after insertion of oral and nasal airways, which made pharyngeal obstruction much less likely.

Krodel DJ, Bittner EA, Abdulnour RE, Brown RH, Eikermann M. Negative pressure pulmonary edema following bronchospasm. Chest. 2011;1405:1351-1354. [CrossRef] [PubMed]
 
Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N. Postoperative complications in patients with obstructive sleep apnea. Chest. 2012;1412:436-441. [CrossRef] [PubMed]
 
Flum DR, Belle SH, King WC, et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium Longitudinal Assessment of Bariatric Surgery (LABS) Consortium Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;3615:445-454. [CrossRef] [PubMed]
 
Hwang D, Shakir N, Limann B, et al. Association of sleep-disordered breathing with postoperative complications. Chest. 2008;1335:1128-1134. [CrossRef] [PubMed]
 
Bateman BT, Eikermann M. Obstructive sleep apnea predicts adverse perioperative outcome: evidence for an association between obstructive sleep apnea and delirium. Anesthesiology. 2012;1164:753-755. [CrossRef] [PubMed]
 
Chaudhary BA, Ferguson DS, Speir WA Jr. Pulmonary edema as a presenting feature of sleep apnea syndrome. Chest. 1982;821:122-124. [CrossRef] [PubMed]
 

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References

Krodel DJ, Bittner EA, Abdulnour RE, Brown RH, Eikermann M. Negative pressure pulmonary edema following bronchospasm. Chest. 2011;1405:1351-1354. [CrossRef] [PubMed]
 
Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N. Postoperative complications in patients with obstructive sleep apnea. Chest. 2012;1412:436-441. [CrossRef] [PubMed]
 
Flum DR, Belle SH, King WC, et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium Longitudinal Assessment of Bariatric Surgery (LABS) Consortium Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;3615:445-454. [CrossRef] [PubMed]
 
Hwang D, Shakir N, Limann B, et al. Association of sleep-disordered breathing with postoperative complications. Chest. 2008;1335:1128-1134. [CrossRef] [PubMed]
 
Bateman BT, Eikermann M. Obstructive sleep apnea predicts adverse perioperative outcome: evidence for an association between obstructive sleep apnea and delirium. Anesthesiology. 2012;1164:753-755. [CrossRef] [PubMed]
 
Chaudhary BA, Ferguson DS, Speir WA Jr. Pulmonary edema as a presenting feature of sleep apnea syndrome. Chest. 1982;821:122-124. [CrossRef] [PubMed]
 
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