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Logo of mjafiGuide for AuthorsAbout this journalExplore this journalMedical Journal, Armed Forces India
 
Med J Armed Forces India. 2005 July; 61(3): 306.
Published online 2011 May 30. doi:  10.1016/S0377-1237(05)80197-2
PMCID: PMC4925578

Pulmonary Oedema in a Survivor of Suicidal Hanging: Reply

Dear Editor,

The authors wish to place on record their appreciation of the interest shown and queries rightly raised by the discerning reader.

As mentioned aspiration was possibily in a patient who was unconscious and had an unprotected airway. The patient was brought to the hospital via Medicare centre in left lateral position within an hour of the incident. In the ICU, the patient had copious pink frothy secretion. She was incubated and mechanical ventilation instituted.

Postoperative pulmonary oedema (POPE) was suspected for the following reasons:

  • i)
    Post obstructive oedema occurred in a setting of acute airway obstruction (hanging). Development of pulmonary oedema was rapid and without warning. The patient was young and apparently healthy female [1]. POPE can occur within 60 mins of a precipitating event or the onset in some cases has been delayed up to 6 hours [2].
  • ii)
    Presence of tachycardia, tachypnoea, frothy pink pulmonary secretions, rales and progressive oxygen desaturation suggests diagnosis of POPE in appropriate setting viz suicidal hanging here. Chest X-Ray finding of pulmonary odoema supports the diagnosis. Other causes of pulmonary oedema are also to be considered. History of normal cardiac function and occurrence of such symptoms in a vigorous young adult point to POPE. Gastric contents in pulmonary secretion were not ascertained, absence of which, would have undoubtedly supported the diagnosis of POPE.
  • iii)
    Majority of cases of POPE respond to prompt, appropriate treatment. However there is a reported case of POPE in an otherwise healthy patient who progressed to acute respiratory distress syndrome and death [3].
  • iv)
    In most reported cases treatment for POPE consists of supplemental oxygen and low levels of PEEP (5cms H2O) yet it is not clear if PEEP is needed. In our case we used PEEP of 15cms H2O tapered down to 10 by fourth day, 4cms H2O by fifth day; extubated on sixth day. The use of PEEP was guided by SpO2 monitoring. ABG was not available.
  • v)
    Clinical findings in aspiration pneumonitis following aspiration of particulate matter depend on extent of endobronchial obstruction and range from acute apnoea to recurrent infection. Chest X-ray in aspiration is seen as infiltrates in one or both lower lobes. Resolution of radiological findings may take up to six weeks [4].

To conclude, though aspiration could have coexisted, our aim in putting up this case report was to highlight the possibility of POPE developing rapidly and without warning following acute airway obstruction. In a series of chest radiographs in children intubated for acute upper airway obstruction, 29 percent developed radiographic evidence of POPE[5]. While these series represent experiences in a tertiary care setting, the surprising frequency of POPE suggests that it is not rare. Rapid recovery can be expected with appropriate management if proper ventilatory and investigative facilities (ABG) are available.

References

1. Holmes JR, Hensinger RN, Wojtys EW. Postoperative pulmonary edema in young, athletic adults. Am J Sports Med. 1991;19:365–712. [PubMed]
2. Lang SA, Duncan PG, Shephard DA, Ha HC. Pulmonary oedema associated with airway obstruction. Can J Anaesth. 1990;37:201–208. [PubMed]
3. Adolph MD, Oliver AM, Dejak T. Death from adult respiratory distress syndrome and multiorgan failure following acute upper airway obstruction. Ear Nose Throat J. 1994;73:324–327. [PubMed]
4. Levison Mathew E. Pneumonia, including necrotizing pulmonary infections. 15th ed. Harrison's principles of internal medicine; 2001. p. 255. Part 9;Sec 2.
5. Sofer S, Bar-Ziv J, Scharf SM. Pulmonary edema following relief of upper airway obstruction. Chest. 1984;86:401–403. [PubMed]

Articles from Medical Journal, Armed Forces India are provided here courtesy of Elsevier