ANESTH ANALG 1127
1983;62:1127-8
Respiratory Obstruction from Uvular Edema in a Pediatric Patient
Kenneth A. Haselby, MD, and William L. McNiece, MD
Uvular edema with upper airway obstruction has been
reported previously in adults as a complication of gen-
eral anesthesia (1-3). It has not been recognized as a
cause of stridor in the pediatric population (4). We
report a case of postoperative development of airway
obstruction resulting from uvular edema in a young
child.
Case Report
A 20-month-old 10.8-kg boy was admitted as an out-
patient for electroretinography under general anes-
thesia. He had an uneventful anesthetic with tracheal
intubation at age 6 months for electroretinography.
There was no family history of anesthesia-related
problems. He had no known allergies and was re-
ceiving no medicines. He had a recent history of mild
coryza without other evidence of upper respiratory
tract infection. Preoperative physical examination and
complete blood count were normal except for mild
coryza. After establishment of an intravenous infu-
sion and the intravenous administration of atropine,
anesthesia was induced with thiopental followed by
succinylcholine. After ventilation with 100% oxygen
by mask, the trachea was intubated uneventfully with
a 4.0-mm inside diameter orotracheal tube. Anes-
thesia was maintained with halothane and nitrous
oxide-oxygen using assisted ventilation. At the con-
clusion of the 50-min procedure, the anesthetic gases
were discontinued, and after demonstration of the
presence of protective airway reflexes, the pharynx
was suctioned and the trachea extubated.
The chdd was taken to the recovery room and placed
in a mist tent with an F I of~0.26.
~ The recovery room
course was uneventful, and after a 45-min stay, he
was dressed and carried in an upright position to an
adjacent waiting area. Forty-five minutes later as the
child was moved from a recumbent to upright po-
Received from the Department of Anesthesia, Indiana Univer-
sity, Indianapolis, Indiana. Accepted for publication July 21, 1983.
Address correspondence to Dr. McNiece, Department of Anes-
thesia, Fesler Hall, Room 204, 1120 South Drive, Indianapolis, IN
46223.
0 1983 by the International Anesthesia Research Society
sition, he suddenly had an episode of gagging and
choking and became cyanotic. He was quickly re-
turned to the adjacent recovery room, placed in the
supine position and given 100% oxygen by mask. The
maneuvers resulted in the immediate abatement of
all symptoms.
Careful auscultatory examination in the supine po-
sition was completely negative and the hypothesis
that he had had some type of retching episode was
considered. However, when he was again picked up
and held in the upright position, he immediately de-
veloped gagging and choking with complete airway
obstruction. He again became cyanotic and actively
sought the recumbent position. The airway sound
associated with the episode were atypical of those
commonly encountered in the postoperative period.
Subsequent direct laryngoscopy demonstrated a mas-
sively swollen and almost translucent uvula. When
the child had assumed the upright posture the uvula
had fallen upon the glottic opening and the airway
became completely occluded.
Neither nebulized racemic epinephrine nor intra-
venous dexamethasone were effective in reducing the
edema. After 2 hr of observation, during which the
child was entirely comfortable in the supine position,
it was decided to observe the child further in the
intensive care unit. Therapy consisted of humidified
air by tent, intravenous hydration, and two additional
doses of dexamethasone. A repeat visual examination
of the uvula 7 hr postoperatively was unchanged.
Direct examination the following morning demon-
strated a mildly erythematous but normal sized uvula.
After the child was fed uneventfully he was dis-
charged from the hospital. He was afebrile through-
out the hospital course and there was no family his-
tory of similar episodes.
Discussion
Many causes for upper airway edema are recognized.
They include mechanical, chemical, and thermal
trauma, allergic reactions, infection, and nonallergic
complement-mediated disorders. Each of these etiol-
ogies is associated with characteristic clinical reac-
1128 ANESTH ANALG
1983;621127-8
tions. Allergic reactions to drugs can occur rapidly
but usually involve other evidence of a reaction in-
cluding cutaneous flushing and wheals, broncho-
spasm, and hypotension. Infection in the form of
epiglottitis or diphtheria is usually slower in onset.
Complement-mediated disorders, notably angioneu-
rotic edema, can result in severe upper airway edema,
but usually other airway structures are also involved
and often there is a family history of the disorder.
Trauma as a cause of upper airway edema is well
recognized. Mechanical causes, including upper air-
way instrumentation and surgical procedures, may
cause edema if not carefully performed. However, the
edema is localized to the area of instrumentation.
Chemical trauma is frequent after inhalational injury
or ingestion of caustic substances. Laryngeal reactions
to tracheal tubes or their cleaning solutions are usually
associated with reactions of other tissues in the air-
way, especially infraglottic structures. Thermal inju-
ries, including iatrogenic thermal injury due to use of
therapeutic humidified systems in which tempera-
tures of the gases before delivery to the patient are
not carefully monitored, can also result in upper air-
way edema.
Previously reported cases of postanesthetic uvular
edema have all involved adult patients. Two of these
patients developed edema about 24 hr after the an-
esthetic, while a third developed edema about 45 min
postoperatively. Suggested etiologies included al-
lergy to atropine and trauma associated with tracheal
tubes, nasogastric tubes, and/or pharyngeal airways.
We have been unable to implicate any of the usual
causes of upper airway edema to explain the devel-
opment of this child’s uvular edema. There was no
CLINICAL REPORTS
other evidence of infectious, allergic, or immunologic
problem. The tracheal tube used was a disposable
tube meeting 2-79 standards. The anesthesia circuit
used contained a heater-humidifier, but the temper-
ature of the output of this system was monitored con-
tinually and the system included an alarm in case
temperature of humidified gases became too elevated.
The child did have mild coryza, perhaps in association
with an undetected pharyngitis. Perhaps laryngos-
copy and tracheal intubation resulted in swelling of
the previously inflamed structures. However, no an-
atomic abnormality was detected during the initial
intubation, and we have not previously seen signif-
icant uvular edema after intubation in patients with
active upper respiratory infections.
The value of this report is twofold. First, uvular
edema should be recognized as another potential cause
of stridor, airway obstruction, and cyanosis in chil-
dren during the postoperative period. Second, 45 min
after the conclusion of the anesthetic this patient was
apparently well. However, 90 min after the anesthetic
the child developed a potentially fatal anesthetic com-
plication. The possible development of such a prob-
lem emphasizes the importance of an adequate du-
ration of postanesthesia observation for outpatients.
References
1. Ravindran R, Priddy S . Uvular edema, a rare complication of
endotracheal intubation. Anesthesiology 1978;48:374.
2. Siegne TD, Felske A, DelGiudice PA. Uvular edema. Anesthe-
siology 1978;49:375-6.
3. Shulman MS. Uvular edema without endotracheal intubation.
Anesthesiology 1981;55:82-3.
4. Maze A, Bloch E. Stridor in pediatric patients. Anesthesiology
1979;50132-45.