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Pulmonary edema

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Pulmonary edema
Pulmonary edema
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Pulmonary edema

  1. 1. Pulmonary Edema
  2. 2. Outline 0 Definition 0 Epidemiology 0 Pathophysiology 0 Classifications & causes 0 Pathogenesis 0 Staging 0 Clinical manifestations 0 Complications 0 Differential diagnosis
  3. 3. Definition Pulmonary Edema ; is a condition characterized by fluid accumulation in the lungs caused by extravasation of fluid from pulmonary vasculature in to the interstitium and alveoli of the lungs
  4. 4. 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
  5. 5. 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.
  6. 6. 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
  7. 7. 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)
  8. 8. 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
  9. 9. 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
  10. 10. Classification Base on underlining cause oCardiogenic pulmonary edema oNon-cardiogenic pulmonary edema
  11. 11. 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. oHydrostatic pressure is increased and fluid exit capillary at increased rate
  12. 12. Cardiogenic PE 0 Basic pathophysiology: A rise in pulmonary venous and pulmonary capillary pressures pushes fluid into the pulmonary alveoli and interstitium.
  13. 13. 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 `
  14. 14. Risk Factors 0 Vary by cause -Leading risk factor is clearly underlying cardiac disease.
  15. 15. Causes of Cardiogenic PE 0LV failure is the most common cause. 0Dysrhythmia 0LV hypertrophy and cardiomyopathy 0 LV volume over load 0Myocardia infarction 0 left ventricular outflow obstruction
  16. 16. 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
  17. 17. 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. oCharacterized by intra pulmonary shunt with hypoxemia and decrease lung compliance
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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.
  22. 22. 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.
  23. 23. 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)
  24. 24. 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
  25. 25. 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
  26. 26. Clinical manifestation Symptom 0 Acute (sudden) 0 Chronic (long-term)
  27. 27. 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
  28. 28. 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
  29. 29. 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…..
  30. 30. 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
  31. 31. 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
  32. 32. 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.
  33. 33. Differential diagnosis 0Pneumothorax 0Bronchitis 0Cardiac tamponed 0COPD 0Pericarditis 0Pneumonia (bacterial ,viral , PCP) 0Pulmonary embolism 0Shocks (cardiogenic ,septic ,anaphylactic) 0Venous air embolism
  34. 34. 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 -.
  35. 35. 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
  36. 36. 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
  37. 37. 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) History Taking Approach a Patient with Pulm.Edema
  38. 38. 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
  39. 39. Past Medical History COPD,  heart failure,  HIV risk factors (pulmonary Kaposi’s sarcoma).  Prior chest X-rays, CT scans, tuberculin testing (PPD).
  40. 40. Medications 0 Anticoagulants 0 Aspirin 0 NSAIDs 0 Narcotic 0 Heroin 0 Morphine 0 Methadone and 0 Dextropropoxyphene
  41. 41. Physical Examination General Appearance Vital signs HEENT Lymphoglandular system Respiratory system Cardiovascular system Abdomen Musculoskeletal……
  42. 42. Laboratory Investigations Routine; CBC Liver function tests Renal Function Tests Arterial blood gas analysis Serum cardiac biomarkers
  43. 43. INVESTIGATION Imaging  chest radiography Echocardiography Ultrasound
  44. 44. 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.
  45. 45. Treatment approach Emergence management -Support of oxygenation and ventilation -oxygen therapy -positive pressure ventilation 0 Reduction of pre load -loop diuretics -nitrate - morphine
  46. 46. Treatment approach reduction of after load and inotropic support condition that complicate PE must be corrected -infection -academia -renal failure -anemia

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