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Pulmonary edema

  1. 1. Dr. Amna Akram CMH, Multan
  2. 2.  Pulmonary edema is a condition characterized by fluid accumulation in the lungs caused by extravasation of fluid from pulmonary vasculature into the interstitium and alveoli of the lungs
  3. 3.  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
  4. 4.  Based on underlying cause  Cardiogenic pulmonary edema  Non-cardiogenic pulmonary edema  Neurogenic PE  High Altitude PE  Post Aspiration PE  Re-expansion PE  Other ( inhaled toxins, lymphatic obstruction, post lung transplant, etc.)
  5. 5.  Due to cardiac abnormalities, pulmonary capillary pressure is increased that increases the pulmonary venous pressure.  CAUSES :  LV failure is the most common  Dysrhythmia  LV hypertrophy and cardiomyopathy  LV volume overload  Myocardial infarction  LV outflow obstruction
  6. 6. Left sided heart failure Decreased pumping ability to the systemic circulation Congestion and accumulation of blood in pulmonary area Fluid leaks out of intravascular space to the interstitium Accumulation of fluid Pulmonary edema
  7. 7.  Neurogenic PE Patients with CNS disorders and without apparent preexisting LV dysfunction  Re-expansion PE Develops after removal of air or fluid, post-thoracocentesis
  8. 8.  High Altitude PE  Occurs in young people who have quickly ascended to altitudes above 2700m and who then engage in strenuous physical exercise at that altitude, before they have become acclimatized  Reversible (in less than 48 hours)
  9. 9.  Based on the degree of fluid accumulation  Stage- 1:all excess fluid can still be cleared by lymphatic drainage  Stage- 2 presence of interstitial edema  Stage- 3 alveolar edema
  10. 10.  Mild: Only engorgement of pulmonary vasculature.  Moderate: Extravasation of fluid into the interstitial space due to changes in oncotic pressure  Severe: Alveolar filling occurs
  11. 11. Symptoms: ACUTE  Severe shortness of breath  Cough- with pink frothy sputum  Profuse sweating  Cyanosis  Anxiety, restlessness  Palpitation  Chest pain
  12. 12.  LONG TERM (CHRONIC)  Paroxysmal nocturnal dyspnea  Orthopnea  Rapid weight gain  Loss of appetite  Fatigue  Ankle and leg swelling
  13. 13.  Tachycardia  Tachypnea  Confusion  Agitation, anxious  Diaphoriesis  Hypertension  Cool extremities  Crepitant rales, ronchi or wheeze  CVS findings: S3, accentuation of pulmonic component of S2, jugular venous distension
  14. 14.  leg edema  Ascites  Pleural effusion  Congestion and swelling of liver  Myocardial infarction  Cardiogenic shock  Arrythmias  Electrolyte disturbances  Mesenteric insufficiency  Protein enteropathy  Respiratory arrest and death
  15. 15. Cardiogenic PE Non cardiogenic PE CVS findings: - S3 gallop - Elevated JVP - Peripheral edema - relatively normal in early stages cardiomegaly Heart size is normal Engorgement of vasculature to the apices No engorgement Pleural effusion is common uncommon
  16. 16. Cardiogenic PE Non cardiogenic PE Perihilar alveolar infiltrate Uniform alveolar infiltrate Kerley B lines Not present Hypoxemia due to ventilation perfusion miss match Hypoxemia due to intrapulmonary shunting Responds to administration of oxygen Persist despite oxygen supplementation
  17. 17.  CBC – severe anemia  Serum electrolytes – Hypokalemia, Hypomagnesemia  Pulse oximetry – assess  Hypoxia  Response to supplemental oxygenation  ABGs – Initially hypoxia and hypocapnia with respi. Alkalosis - Later Hypercapnia with respi and metabolic acidosis
  18. 18.  ECG- tachydysrhythmia - bradydysrhythmia - acute MI  Ultrasonography – B lines sensitivity of 94.1% specificity of 92.4%  Chest x-ray- 1. enlarged heart 2.inverted blood flow 3. Kerley lines 4. Basilar edema (vs diffuse edema) 5. Absence of air bronchograms 6. bilateral and symmetrical pleural effusions
  19. 19. Bat wing edema in a 71-year-old woman with fluid overload and cardiac failure.
  20. 20. Neurogenic PE in a patient with subdural hematoma. Bilateral alveolar filling process and a normal- sized heart.
  21. 21. Patient admitted with progressive respiratory distress 24 hours after arriving at town at 2700 meters above sea level. Right greater than left indistinct airspace opacity
  22. 22. 12 hours later ( same patient) Marked improvement in airspace opacity.
  23. 23. Echocardiography –  acute papillary muscle rupture  acute VSD  cardiac temponade  acute severe mitral regurgitation  aortic regurgitation.  Pulmonary arterial catheterization : (Swan-Ganz Catheter)  PCWP >18mmHg indicates CPE.  PCWP <18mmHg indicates NCPE
  24. 24.  Initial management - ABCs of resuscitation  Supplemental oxygen  Mechanical ventilation - noninvasive by face mask  BiPAP  CPAP - invasive as in endotracheal intubation
  25. 25.  3 main goals  1. preload reduction:  (a) Nitroglycerin (sublingual or intravenous) IV NTG -10mcg/min, rapidly uptitrated to more than 100mcg/min - 3mg IV boluses every 5 minutes  (b) Diuretics (loop diuretics) Furosemide
  26. 26.  (c) Nesiritide (recombinant human BNP)  2. Afterload reduction:  (a) ACE inhibitors –  enalapril 1.25mg IV  captopril 25mg sublingually  (b) Angiotensin II receptor blockers –  Valsartan and candesartan  (c) Nitroprusside-  Avoided in acute MI  Prolonged use causes cyanide toxicity , tolerance and reflex tachycardia
  27. 27.  (3)Inotropic Support : (a) Dobutamine (b) Dopamine (c) Norepinephrine  Intra-aortic Balloon pumping –  reduces afterload  Increases cardiac output  Reduces LA pressure and improves CPE
  28. 28.  Resolves within 48-72 hours in majority of patients  Medical care:  oxygen supplementation  Diuretics  Inotropic support  Surgical Care : directed at the neurological insult (e.g., intracerebral hemorrhage, subdural hematoma, etc.)
  29. 29.  Descent and supplemental O2  Tab nifedipine 10mg sublingual or 20mg sustained release 6hrly.  Hydralazine  inhaled nitrous oxide  acetazolamide

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