Cardiorespiratory Arrest in Diabetic Autonomic Neuropathy

To the Editor.—  In The Journal's editorial (240:1755, 1978) on cardiorespiratory arrest in diabetic autonomic neuropathy, Samuel Vaisrub, MD, reviews recent reports that postulate a primarily respiratory, rather than cardiac, mechanism to account for these episodes. This conclusion was based on the fact that most of the arrests occurred in association with factors that interfere with normal respiration. A majority of the patients whose cases were reported, however, were pulseless as well as apneic. This and the suddenness of the failure bespeak against a purely respiratory mechanism.An alternative explanation has been subsequently proposed, based on an additional case that displayed marked vagal hyperexcitability in response to tracheal suction.¹ In diabetic autonomic neuropathy, the loss of restraining influences from the sympathetic system may cause an exaggerated vagal reaction to impulses arising from the tracheobronchial tree (ie, suction, severe cough) and result in an idioventricular cardiac rhythm. On cessation of