Pulmonary Edema
Outline
0 Definition
0 Epidemiology
0 Pathophysiology
0 Classifications & causes
0 Pathogenesis
0 Staging
0 Clinical manifestations
0 Complications
0 Differential diagnosis
Definition
is a condition
Pulmonary Edema ;
characterized by fluid accumulation in
the lungs caused by extravasation of
fluid from pulmonary vasculature in to
the interstitium and alveoli of the lungs
The extent to which fluid accumulates in the interstitium of the
lung depends on the balance of hydrostatic and oncotic forces
within the pulmonary capillaries and in the surrounding tissue.
Hydrostatic pressure
-favors movement of fluid from the capillary into the
interstitium
Oncotic pressure
-favors movement of fluid into the vessel
Maintenance
-lymphatic in the tissue carry away the small amounts of
protein that may leak out
-tight junction of endothelium are impermeable to protein
Epidemiology
0 Pulmonary edema occurs in about 1% to 2% of the general
population.
0 Between the ages of 40 and 75 years, males are affected
more than females.
0 After the age of 75 years, males and females are affected
equally.
0 The incidence of pulmonary edema increases with age and
may affect about 10% of the population over the age of 75
years.
Pathophysiology
imbalance of starling force
-increase pulmonary capillary pressure
-decrease plasma oncotic pressure
-increase negative interstitial pressure
damage to alveolar- capillary barrier
lymphatic obstruction
Disruption of endothelial barrier allow protein to
escape capillary bed and enhance movement of fluid
in to the tissue of the lung
idiopathic or unknown
Classification
0 based on inciting mechanism
1. Imbalance of Starling force
A. Increased pulmonary capillary pressure
-left ventricular failure
-Volume overload
B. Decreased plasma oncotic pressure
- Hypoalbuminemia due to different cause
C. Increased negativity of interstitial pressure
-Rapid removal of pneumothorax with large
applied negative pressures (unilateral)
Classification
Based on inciting agent…..
2. Altered alveolar-capillary membrane
permeability
o Infectious pneumonia
o Inhaled toxins
o Circulating foreign substances
o Aspiration
o Endogenous vasoactive substances
o Disseminated intravascular coagulation
o Immunologic—hypersensitivity pneumonitis, drugs
o Shock lung in association with non-thoracic trauma
o Acute hemorrhagic pancreatitis
Classification
0 Based on inciting agent….
3. Lymphatic insufficiency
-After lung transplant
- Lymphangitic carcinomatosis
-Fibrosing lymphangitis
4. Unknown or incompletely understood
- High-altitude pulmonary edema
- Neurogenic pulmonary edema
- Narcotic overdose
- Pulmonary embolism
- Eclampsia
-After anesthesia
- After cardiopulmonary bypass
Classification
Base on underlining cause
o Cardiogenic pulmonary edema
o Non-cardiogenic pulmonary edema
Cardiogenic pulmonary edema
Is Pulmonary edema due to increased pressure
in the pulmonary capillaries because of cardiac
abnormalities that lead to an increase in
pulmonary venous pressure.
o Hydrostatic pressure is increased and fluid
exit capillary at increased rate
Cardiogenic PE
0 Basic pathophysiology:
A rise in pulmonary venous and pulmonary
capillary pressures pushes fluid into the
pulmonary alveoli and interstitium.
Pathogenesis of CPE
Left sided heart failure
Decrease pumping ability to the systemic circulation
Congestion & accumulation of blood in the pulmonary area
Fluid leaks out of the intravascular space to the interstitium
Accumulation of fluid
`
Pulmonary edema
Risk Factors
0 Vary by cause
-Leadingrisk factor is clearly underlying
cardiac disease.
Causes of Cardiogenic PE
0 LV failure is the most common cause.
0 Dysrhythmia
0 LV hypertrophy and cardiomyopathy
0 LV volume over load
0 Myocardia infarction
0 left ventricular outflow obstruction
Non cardiogenic pulmonary
edema
It is defined as the evidence of alveolar fluid
accumulation with out hemodynamic
evidence that suggest a cardiogenic etiology.
Hydrostatic pressure is normal
Leakage of protein and other molecule in to
the tissue
Non cardiogenic PE
o Associated with dysfunction of surfactant
lining the alveoli, increased surface force and a
propensity for the alveoli to collapse at low
volume.
o Characterized by intra pulmonary shunt with
hypoxemia and decrease lung compliance
Non cardiogenic pulmonary
edema
Mechanism include:
0Increased alveolar–capillary
membrane permeability
0Decreased plasma oncotic pressure
0Increased negativity of pulmonary
interstitial pressure
0Lymphatic insufficiency or obstruction
Non- cardiogenic PE
0 cause
I. Direct injury to the lung
II. Hematogenous injury to the lung
III. possible lung injury plus elevated
hydrostatic pressure
Staging of PE
Three stages of PE can be distinguished based on the
degree of fluid accumulation:
Stage-1 : all excess fluid can still be cleared by
lymphatic drainage.
Stage-2 : characterized by the presence of interstitial
edema.
Stage-3 : characterized by alveolar edema due to altered
alveolor- capillary permeability
0Mild: Only engorgement of pulmonary
vasculature is seen.
0Moderate: There is extravasation of
fluid into the interstitial space due to
changes in oncotic pressure.
0Severe: Alveolar filling occurs.
Unusual type pulmonary
edema
Neurogenic pulmonary edema
0 Patients with central nervous system disorders and
without apparent preexisting LV dysfunction
Re-expansion pulmonary edema
0 Develops after removal of air or fluid that has been in
pleural space for some time, post- thoracentesis
0 Patients may develop hypotension or oliguria
resulting from rapid fluid shifts into lung.
Unusual type pulmonary
edema
High altitude pulmonary edema
0 occurs in young people who have quickly ascended to
altitudes above2700m and who then engage in
strenuous physical exercise at that altitude, before
they have become acclimatized.
0 Reversible (in less than
48 hours)
Pathophysiology
on ascending to high altitude, falling level of Po2 trigger hypoxic
pulmonary vasoconstriction
This directs blood flow away from hypoxic areas of lung towards
area that are well oxygenated
This results in a rise in mean pulmonary artery pressure & a
heterogeneous blood flow to different parts of the lung
Cont…
0 In areas that receive high blood flow the capillary trans-
mural pressure rises & walls of the capillary &alveolus are
exposed to stress failure
0 Extensive damage to alveolar capillary membrane
0 Edema which is rich in high molecular weight proteins &
RBCs to pass freely in to the alveoli & impair oxygenation.
0 patient present with
Headache, Insomnia, Fluid retention, Cough,Shortness of
breath
Clinical manifestation
Symptom
0 Acute (sudden)
0 Chronic (long-term)
Symptom
ACUTE
0 Shortness of breath
0 A Feeling of suffocating
0 Anxiety ,restlessness
0 Cough-frothy sputum that may be tinged with blood
0 excessive sweating
0 pale skin
0 chest pain if PE is cause by cardiac abnormality
0 palpitation
symptom
Long term(chronic)
0 Paraxosomal nocturnal dyspnea
0 orthopnea
0 Rapid weight gain
0 Loss of appetite
0 fatigue
0 ankle and leg swelling
Sign
0 Tachycardia
0 Tachypnea
0 Confusion
0 Agitation
0 Anxious
0 Diaphoric
0 Hypertension
0 Cool extremities
0 Rales
0 Wheezing
0 CVS findings ; S3 ,accentuation of pulmonic component of S2,
jugular venous distention…..
Special considerations
Unilateral pulmonary edema after rapid evacuation of
large pneumothorax
0 Findings may be apparent only by radiography.
0 Occasionally, dyspnea with physical findings localized to
edematous lung
Special consideration
Lymphatic blockade secondary to fibrotic and
inflammatory diseases or lymphangitic
carcinomatosis
0 Both clinical and radiographic manifestations are
dominated by the underlying disease process.
Neurogenic pulmonary edema
0 Symptoms usually occur within minutes to hours of the
injury
Complications
leg swelling(edema),
abdominal swelling(ascites),
Pleural effusion,
Congestion & swelling of liver,
acute heart attack (myocardial infarction [MI]),
cardiogenic shock,
arrhythmias,
electrolyte disturbances,
mesenteric insufficiency,
protein enteropathy,
respiratory arrest, and death.
Differential diagnosis
0 Pneumothorax
0 Bronchitis
0 Cardiac tamponed
0 COPD
0 Pericarditis
0 Pneumonia (bacterial ,viral , PCP)
0 Pulmonary embolism
0 Shocks (cardiogenic ,septic ,anaphylactic)
0 Venous air embolism
Distinguishing Cardiogenic from Non-
cardiogenic Pulmonary Edema
Finding suggesting cardiogenic edema
-S3 gallop
-elevated JVP
-Peripheral edema
Findings suggesting non-cardiogenic edema
-Pulmonary findings may be relatively normal in
the early stages
-.
Distinguishing …..
Chest radiography
A cardiogenic cause is favored with
0 Cardiomegaly
0 Kerley B lines and loss of distinct vascular margins
0 Cephalization: engorgement of vasculature to the apices
0 Perihilar alveolar infiltrate
0 Pleural effusion
Non cardiogenic cause
-Heart size is normal
-Uniform alveolar infiltrate
-pleural effusion is uncommon
-lack of cephalization
Distinguishing…..
Hypoxemia
0 Cardiogenic
- due to ventilation perfusion miss match
-respond to administration of oxygen
0 Non cardiogenic
-due to intrapulmonary shunting
-persist despite oxygen supplimentation
Approach a Patient with
Pulm.Edema
History Taking
Exertional Dyspnea
Orthopnea
Aspiration of food or foreign body
Direct Chest injuries
Walking High altitude
Chest Pain(right or left)
Leg pain or swelling(Pulmonary Embolism)
A cough that produces frothy sputum that may be tinged
with blood(cardiogenic)
Cont…
Palpitations
Excessive sweating
Skin color change-Pale skin
Chest pain(if it is Cardiogenic)
Rapid weight gain(cardiogenic)
Fatigue
Loss of appetite
Smoking History
Past Medical History
COPD,
heart failure,
HIV risk factors
(pulmonary Kaposi’s sarcoma).
Prior chest X-rays,
CT scans,
tuberculin testing (PPD).
Medications
0 Anticoagulants
0 Aspirin
0 NSAIDs
0 Narcotic
0 Heroin
0 Morphine
0 Methadone and
0 Dextropropoxyphene
Physical Examination
General Appearance
Vital signs
HEENT
Lymphoglandular system
Respiratory system
Cardiovascular system
Abdomen
Musculoskeletal……
Laboratory Investigations
Routine; CBC
Liver function tests
Renal Function Tests
Arterial blood gas analysis
Serum cardiac biomarkers
INVESTIGATION
Imaging
chest radiography
Echocardiography
Ultrasound
INVESTIGATION…..
Pulmonary artery catheterization
indicated when;
-Cause remains uncertain
-Pulmonary edema which is refractory to therapy
-PE accompanied by hypotension
Pulmonary capillary wedge pressure < 18 mmHg is
consistent with a non-cardiogenic cause.
Pulmonary capillary wedge pressure >20 mmHg
favors a cardiogenic cause.
Treatment approach
Emergence management
-Support of oxygenation and ventilation
-oxygen therapy
-positive pressure ventilation
0 Reduction of pre load
-loop diuretics
-nitrate
- morphine
Treatment approach
reduction of after load and inotropic support
condition that complicate PE must be corrected
-infection
-academia
-renal failure
-anemia
