Pulmonary edema is fluid accumulation in the lungs that impairs gas exchange and can cause respiratory failure. Cardiac failure occurs when the heart cannot maintain adequate cardiac output or can only do so with elevated filling pressure. Left ventricular failure can be systolic, with reduced contractility, or diastolic, with impaired relaxation. Common causes include coronary artery disease, myocardial infarction, cardiomyopathy, and valvular heart disease. Treatment involves oxygen, diuretics, ACE inhibitors, beta blockers, and management of triggers like infections, arrhythmias, and electrolyte imbalances.

1. Pulmonary edema
Dr.Gireesh kumar.K.P

2. Pulmonary edema and cardiac failure
• Pulmonary edema is fluid accumulation in the tissue and
air spaces of the lungs. It leads to impaired gas exchange
and may cause respiratory failure.
• Cardiac failure is defined as a state in which the heart can
not maintain an adequate cardiac output or can do so
with an elevated filling pressure

3. Left ventricular failure - and causes
• In left ventricular systolic failure, there is reduced cardiac
contractility, where as in diastolic heart failure there is
impaired cardiac relaxation and abnormal ventricular
filling.
• Left ventricular systolic dysfunction - cases are due to
chronic coronary artery disease, MI or chronic angina.
Other causes of left ventricular systolic dysfunction
include idiopathic dilated cardiomyopathy, valvular heart
disease, hypertensive heart disease, toxin-induced
cardiomyopathies (ie, alcohol and doxorubicin), and
congenital heart disease.

4. Triggers of cardiac failure
• Infections, fever, sepsis , Anemia ,Beriberi ,Thyrotoxicosis
• Cardiac arrhythmias, Infective endocarditis
• Excess salt/fluid intake, Stress ,Electrolyte disturbances-
potassium, magnesium
• Steroids, NSAIDS
• Negative inotropes e.g. Calcium channel blockers, such
as verapamil & diltiazem, and Beta blockers

5. Clinical features of cardiac failure
Symptoms Signs
Fatigue,Exercise intolerance
Dyspnea on exertion
Orthopnea, PND
Presyncope, Syncope
Palpitation
Angina
Pedal oedema
Ascites
Elevated JVP
Hepatic congestion,
Hepatosplenomegaly
Pulmonary oedema(Basal
crepitations)

6. Investigations
• Hb % (anaemia to be ruled out)
• Thyroid function test
• Electrolytes – potassium, magnesium, sodium
• Serum creatinine (renal failure):

7. Chest X ray (pulmonary oedema)
• DD:Cardiogenic
pulmonary edema,
• ARDS,Viral pneumonia,
Eosinophilic
pneumonia,TB

8. B-type natriuretic peptide
• BNP is a 32 amino acid polypeptide secreted by the ventricles of
the heart in response to excessive stretching of heart muscle cells
• BNP is increased in patients with left ventricular dysfunction, with
or without symptoms (BNP accurately reflects current ventricular
status, as its half-life is 20 minutes,
• Levels above 500 pg/ml are generally considered to be positive,
Levels between 100 and 500 pg/ml the test is considered
inconclusive
• BNP can be elevated in renal failure, in the absence of heart
failure.

9. Other investigations
• ECG (Ischaemic changes)
• TMT (Ischaemic changes) in stable cases only
• ECHO(Low Ejection fraction, valvular lesions)
• USG abdomen (congestive hepatosplenomegaly)

10. Acute management
• Oxygen inhalation
• Propped up position /45O
head ed elevation
• S/L Nitroglycerine and IV NTG (if BP is high)
• IV Furosemide 40-80 mg IV , repeat if needed
• Inotropes (NA/Dopamine, Dobutamine) in hypotension
• Non invasive ventilation(BIPAP)

11. Diuretics
• Diuretics produces symptomatic relief
• Start with a thiazide diuretic in very mild failure
(Hydrochlorothiazide 12.5 – 25 mg) OR a loop diuretic
(Furosemide 40mg : Lasix 40 ®)
• Add a potassium-sparing agent, which can reduce
potential hypokalemia (Spironolactone 25 mg)
• Best option Furosemide + Spironolactone
• Lasilactone ® (Frusemide/Spironolactone- 20mg/50mg)

12. Ionotropes
• Sympathomimetic agents
– Dobutamine 2.5 – 15 mcg/kg/min infusion
– Dopamine 2 – 8 mcg /kg /min infusion
• Phosphodiesterase inhibitors
– Milrinone 50 mcg/kg IV bolus over 10 minutes then 0.375 –
0.75 mcg/kg/min,
– Amrinone.
– Levosimendan

13. Salt and water
• 2 gm salt , 1 L fluid /day
• Fluid restriction (eg, 1 - 1.5L /day) only in patients with
refractory HF or symptomatic or severe hyponatremia

14. ACE inhibitors
• Reduces mortality , they should be started in all patients
with heart failure unless contraindicated
• ACE inhibitors stabilize LV remodeling, improve
symptoms, reduce hospitalization, and improves quality of
life.
• T. Captopril 6.25 mg 6th hourly, increase up to 50 mg TID
• T. Enalapril 2.5 mg BD, increase up to 10 mg TID
• T. Ramipril 1.25 mg BD, increase up to 5 mg BD
• T. Losartan 25 - 50 mg OD

15. Betablocker
• These drugs can improve symptoms, exercise tolerance,
cardiac hemodynamics, and LV ejection fraction and that
they decrease mortality rates in patients with cardiac
failure, especially those with both ischemic and idiopathic
cardiomyopathy
• Start with very low dose, then slowly increase.

16. Digoxin
• Indicated in cardiac failure with associated atrial
fibrillation , it less effective when patients are in sinus
rhythm but it has been shown to reduce rates of
hospitalization for symptom control although there is no
significant effect on mortality
• T. Digoxin 0.125 -0.25 mg OD, 5 days in a week