64 YOM with pmhx notable for CHF/CAD presents with 3 days T 98.7 P 110 BP 180/80 worsening dyspnea with exertion. O2 92% (ra), RR 22 He can usually easily walk from room to room in his home however in the last three days he has been unable to Gen: WDWN, anxious cross a room without stopping to catch his breath. The patient denies CV: Tachycardic, RR, outright chest pain/ diaphoresis any recent cough/congestion, fevers or cr<3 sec. chills. This episode is reminiscent of his “heart failure acting up” He has Pulm: Lungs show poor been using his medications as prescribed. At presentation he has air movement with rales mild increased work of breathing; he is speaking in 5-7 word sentence from the mid lung fragments. He is awake/alert. fields to the bases bilaterally. Abd: s/nt/nd Ext: no cy/cl/ed
Note mild interstitial pulmonary edema in a patient with likely poorly controlledhypertension and hypertensive cardiomyopathy.PA/Lateral films show signs of interstitial pulmonary edema (increased interstitialmarkings).Lateral radiograph—Thickened interlobar fissures (subpleural edema) (12B,black arrowheads),
Pulmonary 100% O2 by face mask should be administered to achieve O2 saturation of >94% by pulse oximetry. If hypoxia persists despite O2 therapy: apply biphasic positive airway pressure via face mask. Unconscious or visibly tiring patients should be intubated.
Cardiac Nitroglycerin should be administered 0.4 mg sublingually (may be repeated q1–5 minutes) or as a topical paste in 1–2 in. If no response or ECG shows ischemia, NTG 10 mcg/min should be initiated as an IV drip and titrated to BP and symptomatic improvement For hypotensive patients or patients in need of additional inotropic support start dopamine 5–10 mcg/kg/min and titrate to systolic BP of 90–100 mm Hg When indicated administer a potent IV diuretic, such as furosemide 40–80 mg IV
Medical management For patients with resistant hypertension or those who are not responding well to NTG: nitroprusside may be used, starting at 2.5 mcg/kg/min and titrated. In the setting of ESRD the definitive treatment of pulmonary edema is volume management with dialysis. Etiology Until excluded, AMI should be considered as the cause of exacerbation. Acute mitral valve or aortic valve regurgitation should be considered, especially if the heart is of normal size, because the patient may need emergency surgery.
Septal lines Septal lines(Kerley B lines) (Kerley B lines)were present later resolvedinitially. after diuresis
-Blurred vascular margins and Blurred vascular margins anddistension of upper zone blood cephalization later resolvedvessels (Cephalization). arrowheads arrowheads.-Peribronchial cuffing (black arrow) Peribronchial cuffing also resolved (white arrow).
Pulmonary edema resolved after several days treatment with diuretic medications.Cardiac enlargement and hilar venous distension (upper zone vascular prominence) alsoimproved.Lateral radiograph shows improvement of thickened interlobar fissures (subpleuraledema).