Drs. Dieu and Upjohn present 2 cases of negative pressure pulmonary edema (NPPE) which, as the authors note, has been reported since 1977. Its incidence of 1 or 2 per 2000 cases suggests that a busy hospital recovery room will have at least 1 such episode per year and that most experienced anesthesiologists and recovery room nurses will have seen or helped manage at least 1 patient with NPPE.

Why report a traditionally anesthesia-managed perioperative problem in Aesthetic Surgery Journal? First, this complication has not been previously reported in patients undergoing cosmetic surgery. Second, it is helpful to emphasize that NPPE can occur in otherwise healthy patients, and so may occur in an outpatient or in-office surgery setting.

The authors suggest that shorter-acting anesthetic agents may play a role in the increased reporting of NPPE, but earlier arousal probably only changes the time at which laryngospasm occurs. The more appropriate concern is preoperative recognition of the patient who is predisposed to having a reactive airway: the heavy smoker; the asthmatic; the patient with gastroesophageal reflux; the patient with chronic sinusitis or rhinitis with posterior pharyngeal drainage; or the patient for rhinoplasty. The occurrence of laryngospasm or marked reaction to the endotracheal tube on arousal is more closely related to these conditions than to the type of anesthetic.

The pathogenesis of NPPE reminds us of our training and why we did not connect a patient’s chest tube to high negative pressures. The symptoms often present dramatically, particularly when the patient is healthy and the blocked inspiratory effort has been strong. The primary treatment is straightforward: a patent airway, oxygen, and positive airway pressure which, in the absence of respiratory therapy support, can be administered using any anesthesia machine. This allows for initial management in facilities with C level AAAASF certification or the equivalent. Urgent transfer to an intensive care unit is still required. Importantly though, the transfer can be one of controlled care.