Pulmonary Edema

Pulmonary Oedema

Pulmonary edema is a clinical term that refers to the abnormal buildup of fluids within the lung tissues that causes physiological disturbances to the patient. Patients usually present with severe left sided heart failure with pulmonary hypertension and alveolar flooding in the lungs.

PulmEdema

PulmEdema, CC BY-SA 3.0

Presentation

Pulmonary edema from different causes can either present acutely or chronically. The following signs and symptoms are commonly seen with pulmonary edema:

Acute dyspnea
Wheezing of lung fields
Feeling of suffocation and drowning
Restlessness and severe anxiety
Productive cough (could be blood tinged)
Palpitations and chest pain
Exercise induced dyspnea
Orthostatic dyspnea (dyspnea while lying down)
Increased weight
Bipedal edema
Fatigue
Fever
Headache and dizziness
Grayish blue skin tone

Respiratoric

Dyspnea

[…] induced dyspnea Orthostatic dyspnea (dyspnea while lying down) Increased weight Bipedal edema Fatigue Fever Headache and dizziness Grayish blue skin tone Pulmonary edema is a medical emergency, thus initial diagnostic modalities are usually limited to[symptoma.com]
Patients underwent repeated dyspnea and lung sonographic assessments using a 10-cm visual analog scale (VAS) and an 8-zone scanning protocol.[ncbi.nlm.nih.gov]
Pulmonary edema typically results in dyspnea. When edematous fluid is large in volume it can redistribute when an individual lies supine, affecting more lung tissue and thus worsening dyspnea, a phenomenon known as orthopnea.[pathwaymedicine.org]
The first distinctive signs are dyspnea and large liquid râles over the lower lobes.[jamanetwork.com]
Patient experienced ecphysesis and dyspnea suddenly after HBO₂ therapy (100% oxygen at 0.25 MPa, for 60 minutes with a five-minute air break and decompression at 0.01 MPa/minute).[ncbi.nlm.nih.gov]

Pneumonia

Five showed definite HAPE with follow-up X-rays within 48 hours confirming rapid clearing on oxygen, 27 showed findings consistent with HAPE or viral pneumonia and no repeat study.[ncbi.nlm.nih.gov]
We retrospectively analyzed 3759 blood gas analysis and clinical parameters of 475 patients presenting with ARF based on acute cardiogenic pulmonary edema and/or pneumonia.[ncbi.nlm.nih.gov]
Pneumonia. Almost all of the signs which indicate pneumonia are exactly the same as HAPE. The only way to tell is by descending.[climbing-high.com]
Pulmonary edema or pneumonia Pulmonary edema can overlap with pneumonia, but it is a different condition. Pneumonia is an infection that often occurs as a complication of a respiratory infection, such as the flu .[medicalnewstoday.com]
See also Edema Pneumonia Pulmonary edema at Wikipedia[house.wikia.com]

Rales

Several factors such as "Serum NT-pro-BNP level   6980 mg/dl," "systemic blood pressure   170 mm Hg," "heart rate   120 bpm," "with rales in breathing sound," "with jugular vein engorgement," "with NYHA Fc III/IV," "with chronic lung disease" and "with[ncbi.nlm.nih.gov]
Chest auscultation reveals rales and rhonchi bilaterally. A chest radiograph shows bilateral pulmonary infiltrates consistent with pulmonary edema and borderline enlargement of the cardiac silhouette.[nejm.org]
The provider will listen to your lungs and heart with a stethoscope to check for: Abnormal heart sounds Crackles in your lungs, called rales Increased heart rate (tachycardia) Rapid breathing (tachypnea) Other things that may be seen during the exam include[medlineplus.gov]

Orthopnea

Outcome and follow-up Over the course of 2 weeks, the shortness of breath and orthopnea subsided gradually and by the fourth night, the patient was able to sleep on one pillow with no orthopnea.[edm.bioscientifica.com]
Orthopnea and paroxysmal nocturnal dyspnea are two variants of shortness of breath seen in association with pulmonary edema. Orthopnea describes shortness of breath while lying flat.[emedicinehealth.com]
[…] exposure Kidney failure Narrowed arteries that bring blood to the kidneys Lung damage caused by poisonous gas or severe infection Major injury Symptoms of pulmonary edema may include: Coughing up blood or bloody froth Difficulty breathing when lying down (orthopnea[medlineplus.gov]

Pulmonary Disorder

However, the development of pulmonary disorders after EV71 infection remains largely unknown.[ncbi.nlm.nih.gov]
Other factors that may put a person at risk include: history of pulmonary edema history of lung disease, such as tuberculosis or chronic obstructive pulmonary disorder (COPD) vascular, or blood disorders You doctor will look for fluid in your lungs, or[healthline.com]
Other factors that may put a person at risk include: history of pulmonary edema history of lung disease, such as tuberculosis or chronic obstructive pulmonary disorder (COPD) vascular, or blood disorders Diagnosis of pulmonary edema You doctor will look[healthline.com]

Entire body system

Fatigue

Extreme fatigue/weakness Gurgling sound whilst breathing. If you place an ear to the victim’s chest, you may hear crackling or gurgling noises.[climbing-high.com]
Both can cause a feeling of fatigue and make sleeping difficult. A rapid irregular heartbeat is also common in both conditions. Both of these conditions can be life-threatening if left untreated.[livestrong.com]
Further questioning revealed a history of nocturnal snoring, frequent awakening, and daytime fatigue, suggesting a possible sleep apnea syndrome (SAS).[edm.bioscientifica.com]
Symptom…… Long term(chronic)  Paraxosomal nocturnal dyspnea  orthopnea  Rapid weight gain  Loss of appetite  fatigue  ankle and leg swelling 28.[slideshare.net]

Cardiovascular

Heart Disease

The doctor will inquire only on the important patient history, including pre-existing heart disease, and the circumstances of onset, the presence of trauma or not.[health.ccm.net]
As tributes continue to paid to Munster rugby legend Anthony Foley following his premature death at the age of 42, a French coroner has confirmed he died from pulmonary oedema brought on by heart disease.[irishtimes.com]
Having a lot of long-term stress, smoking and having a family history of heart disease or cardiovascular disease are also risk factors.[rightdiagnosis.com]
Well-established risk factors for heart failure such as hypertension, coronary ischemia, valvular heart disease, and diastolic dysfunction are associated with acute decompensated heart failure as well as with FPE.[ncbi.nlm.nih.gov]
Patients at risk for cardiogenic pulmonary edema may have risk factors for heart disease , including high blood pressure , high cholesterol , diabetes , family history of heart disease , and smoking .[emedicinehealth.com]

Tachycardia

Drowsiness ranks first among risk factors for NPE in children with severe HFMD, followed by vomiting, tachycardia, hypertension, breathing rhythm changes, limb tremors, atypical rash, and hyperglycemia.[ncbi.nlm.nih.gov]
In both procedures, patients developed severe hypertension and tachycardia, with subsequent oxygen desaturations with noted pulmonary edema.[ncbi.nlm.nih.gov]
She subsequently developed agitation, increasing tachypnea and tachycardia, and a persistent cough. Her lungs had diffuse crackles and rhonchi. O[sub]2[/sub] saturation was 85% in room air.[professional.diabetes.org]
If the pulmonary edema is associated with severe tachycardia (or AF and electrical cardioversion failed), pharmacologic rate (and rhythm) control is essential in AS.[casesjournal.biomedcentral.com]
The examination findings are tachycardia, tachypnoea, hypoxia and bibasal inspiratory crepitations. A gallop rhythm may be present. Blood pressure is generally high.[rcemlearning.co.uk]

Cyanosis

In severe degrees of edema the breathing is that of suffocation, there is cyanosis, and there exudes or is expectorated from the mouth a thin serous frothy fluid often tinged with blood.[jamanetwork.com]
The accumulation of fluids in the lungs fill in the air sacs and manifest externally dyspnea, chest pain, and cyanosis.[symptoma.com]
Poor judgement Breathlessness during rest Rapid heart rate (90 to 100 bpm at rest) Blue/grey lips or fingernails (cyanosis) Fever of up to 101.3 F/38.5 C Profuse perspiration All symptoms are worse at night Confusion Collapse Coma Treatment is the same[climbing-high.com]
Accumulation of fluid in the interstitium and alveoli results in varying degrees of respiratory distress and cyanosis due to reduced oxygen transport into pulmonary capillaries.[vetstream.com]
(tachycardia) Rapid breathing (tachypnea) Other things that may be seen during the exam include: Leg or abdominal swelling Abnormalities of your neck veins (which can show that there is too much fluid in your body) Pale or blue skin color (pallor or cyanosis[medlineplus.gov]

Palpitations

Paroxysmal episodes of serious hypertension, headache, palpitation, and diaphoresis are the typical manifestations (Bravo, 2004).[ncbi.nlm.nih.gov]
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 38.[slideshare.net]
The following signs and symptoms are commonly seen with pulmonary edema: Acute dyspnea Wheezing of lung fields Feeling of suffocation and drowning Restlessness and severe anxiety Productive cough (could be blood tinged) Palpitations and chest pain Exercise[symptoma.com]
[…] exertion, which progresses to shortness of breath at rest Cough Difficulty walking uphill, which progresses to difficulty walking on flat surfaces Fever A cough that produces frothy sputum that may be tinged with blood A rapid, irregular heartbeat (palpitations[mayoclinic.org]
[…] with breathing difficulties, other signs and symptoms of acute pulmonary edema can include: cough, often with a pink frothy sputum excessive sweating anxiety and restlessness feelings of suffocation pale skin wheezing rapid or irregular heart rhythm (palpitations[medicalnewstoday.com]

Gallop Rhythm

The heart sounds may be inaudible over the rales from the lungs but a gallop rhythm may be present. Murmurs, especially mitral regurgitation and aortic stenosis, should be listened for, and may reveal a precipitating cause.[rcemlearning.co.uk]
Oxygen saturation is usually Assess for a gallop rhythm (3rd heart sound) and murmurs suggestive of valve stenosis or regurgitation. Hypotension - the triad of hypotension (systolic blood pressure cardiogenic shock .[patient.info]

Urogenital

Kidney Failure

It can be caused by such things as heart or kidney failure, poisoning, or near-drowning.[myhealth.alberta.ca]
It may be caused by congestive heart failure, kidney failure, viral infections, lung illness or injury, smoke inhalation, near-drowning, adverse drug reactions, or exposure to high altitude .[lungmds.com]
Other heart-related problems that can lead to pulmonary edema include: Fluid overload - this can result from kidney failure or intravenous fluid therapy.[medicalnewstoday.com]
failure High altitude exposure Treatment Pulmonary edema is generally treated in the emergency room of hospital, sometimes in an Intensive Care Unit (ICU).[maxhealthcare.in]

Oliguria

[…] nervous system disorders and without apparent preexisting LV dysfunction  Re-expansion pulmonary edema  Develops after removal of air or fluid that has been in pleural space for some time, post- thoracentesis  Patients may develop hypotension or oliguria[slideshare.net]

Neurologic

Headache

Paroxysmal episodes of serious hypertension, headache, palpitation, and diaphoresis are the typical manifestations (Bravo, 2004).[ncbi.nlm.nih.gov]
Mountain climbers should get to lower ground and seek medical attention if they have: Chest discomfort Cough Cough with frothy spit that may have some blood in it Fast, irregular heartbeat Fever Headache Shortness of breath when they’re active that gets[webmd.com]
Feeling of suffocation and drowning Restlessness and severe anxiety Productive cough (could be blood tinged) Palpitations and chest pain Exercise induced dyspnea Orthostatic dyspnea (dyspnea while lying down) Increased weight Bipedal edema Fatigue Fever Headache[symptoma.com]
Headache, nausea and vomiting will cease.1 Gurgling breath sounds and cough will gradually subside over six hours. Cough and fever persisting after 48 hours of treatment suggest the possibility of pneumonia.[publications.americanalpineclub.org]
[…] you sit up rapid weight gain, especially in the legs swelling in the lower part of the body fatigue High altitude pulmonary edema Pulmonary edema due to high altitude sickness, or not getting enough oxygen in the air, will have symptoms that include: headaches[healthline.com]

Dizziness

[…] any of these symptoms, call 911 right away: Sudden shortness of breath Trouble breathing with a lot of sweating Breathing that sounds bubbly or like wheezing or gasping Coughing up pink, frothy spit Skin that looks blue or gray Feeling lightheaded, dizzy[webmd.com]
[…] suffocation and drowning Restlessness and severe anxiety Productive cough (could be blood tinged) Palpitations and chest pain Exercise induced dyspnea Orthostatic dyspnea (dyspnea while lying down) Increased weight Bipedal edema Fatigue Fever Headache and dizziness[symptoma.com]
Other common symptoms may include easy fatigue , more rapidly developing shortness of breath than normal with usual activity (dyspnea on exertion), rapid breathing (tachypnea), dizziness , or weakness.[medicinenet.com]
These include weakness, fatigue , confusion , anxiety and dizziness .[rightdiagnosis.com]

Agitation

She subsequently developed agitation, increasing tachypnea and tachycardia, and a persistent cough. Her lungs had diffuse crackles and rhonchi. O[sub]2[/sub] saturation was 85% in room air.[professional.diabetes.org]
As their hypoxia worsens they may become agitated and with worsening respiratory failure may become hypercapnoeic causing their conscious level to fall.[rcemlearning.co.uk]
In acute pulmonary edema, the patient may be extremely fearful or agitated. Breathlessness, dizziness, and faintness are common complaints.[tele.med.ru]
Signs  Tachycardia  Tachypnea  Confusion  Agitation  Anxious  Diaphoric  Hypertension  Cool extremities  Rales  Wheezing  CVS findings ; S3 ,accentuation of pulmonic component of S2, jugular venous distention….. 29.[slideshare.net]
Although symptoms usually develop within one hour of the precipitating event, delayed onsets have been reported. 5 , 7 , 13 , 15 , 25 , 30 The presence of agitation, tachypnea, tachycardia, frothy pink pulmonary secretions, rales and progressive oxygen[aafp.org]

Workup

Pulmonary edema is a medical emergency, thus initial diagnostic modalities are usually limited to the preliminary physical examination, chest X-ray, and electrocardiography (ECG). When patients are judged to be stable, they will be subjected to the different test and diagnostic procedures as a standard work up for pulmonary edema. The following tests are conducted to patients with pulmonary edema:

Chest X-ray
Pulse oximetry
Blood tests
ECG
Echocardiography
Transesophageal echocardiography (TEE)
Pulmonary artery and cardiac catheterization

X-ray

Kerley B Lines

Other features of cardiogenic pulmonary edema include elevated cardiac enzymes and enlarged cardiac silhouette or the presence of Kerley B lines in CXR (3) .[edm.bioscientifica.com]
Chest X-ray will show fluid in the alveolar walls, Kerley B lines , increased vascular shadowing in a classical batwing peri- hilum pattern, upper lobe diversion (increased blood flow to the superior parts of the lung), and possibly pleural effusions[en.wikipedia.org]
.  Chest radiography A cardiogenic cause is favored with  Cardiomegaly  Kerley B lines and loss of distinct vascular margins  Cephalization: engorgement of vasculature to the apices  Perihilar alveolar infiltrate  Pleural effusion Non cardiogenic[slideshare.net]
On a CXR, cardiogenic pulmonary edema can show; cephalization of the pulmonary vessels, Kerley B lines or septal lines, peribronchial cuffing, "bat wing" pattern, patchy shadowing with air bronchograms, and increased cardiac size.[med-ed.virginia.edu]

Pulmonary Infiltrate

The DAH triad (hemoptysis, anemia, and pulmonary infiltrates) was observed in 50% of episodes (n 9/18), and acute respiratory failure in 94% (n 17/18).[ncbi.nlm.nih.gov]
A chest radiograph shows bilateral pulmonary infiltrates consistent with pulmonary edema and borderline enlargement of the cardiac silhouette.[nejm.org]

Pulmonary Edema on Chest X-Ray

When you see a pulmonary edema on chest x-ray (CXR), the knee jerk reaction is to attribute it to heart failure. But what might you be missing? Not all the glitters is gold. And not all that is wet on CXR is just plain ol’ CHF.[canadiem.org]
A chest X-ray is generally performed to see the size and shape of the heart and can reveal lung congestion, pulmonary edema, and other conditions, such as pneumonia . Other tests may include an imaging test called an echocardiogram.[rightdiagnosis.com]

Bilateral Pulmonary Infiltrate

A chest radiograph shows bilateral pulmonary infiltrates consistent with pulmonary edema and borderline enlargement of the cardiac silhouette.[nejm.org]

Serum

Hypercapnia

Non-invasive ventilation should be considered in dyspnoeic patients with pulmonary oedema and a respiratory rate 20 breaths/minute to improve breathlessness and reduce hypercapnia and acidosis.[patient.info]
Although the BiPAP group had greater reductions in PaCO 2 , systolic blood pressure, mean arterial pressure, and hypercapnia than did the CPAP group, myocardial infarction rates were higher in the BiPAP group (71%) than in the CPAP group (31%) and the[pmj.bmj.com]
[…] positive airway pressure) for BiPAP. 8 Contraindications to non-invasive ventilation include hypotension, possible pneumothorax, vomiting, an altered level of consciousness or non-compliance. 7 If, despite non-invasive ventilation, there is persistent hypercapnia[nps.org.au]

Treatment

Patients presenting with pulmonary edema are usually attached to an oxygen source through mask or nasal cannula to allay the symptoms of dyspnea. Although severe cases presenting with respiratory failure may already require mechanical ventilation [9]. For cardiogenic pulmonary edema, a cardiac preload unloader like furosemide can reduce the accumulation of fluids in the air sacs. In the same way, an afterload reducer like nitroprusside that dilates the systemic vessels and unloads the ventricular workload can mitigate the crisis. Morphine is sometimes given to control chest pain and severe anxiety in patients. Blood pressure regulating medications may also be given with the need arise during the resuscitative phase of pulmonary edema.

Prognosis

The prognosis for patients who subsequently develop congestive heart failure with hydrostatic pulmonary edema is poor. It carries a mean survival time of 1.7 years among males and 3.2 years in females from the time of diagnosis [7]. Most cases of neurogenic pulmonary edema remains underdiagnosed due to the imposing primary disorder that undermines its existence. The relative morbidity of neurogenic pulmonary edema is as high as 50% while its relative mortality rating is as low as 7% [8].

Etiology

The following etiologic factors and medical conditions predispose susceptible patients to pulmonary edema:

Coronary heart disease
Cardiomyopathy
Cardiac valvular diseases
Hypertension
Acute respiratory distress syndrome (ARDS)
Barotrauma in high altitudes
Drug reactions
Viral infections
Intracerebral and subarachnoid hemorrhage [1]
Seizure disorder [2]
Pulmonary embolism
Lung trauma
Toxins
Inhalation injuries
Near drowning

Epidemiology

The American Heart Association (AHA) has reported at 550,000 new cases of cardiogenic pulmonary edema each year in the United States. Congestive heart failure has caused the death of at least 287,000 of these cases in 1999 alone [3]. The lifetime risk for hydrostatic pulmonary edema has practically doubled beyond 40 years of age especially those with hypertension concomitant with congestive heart failure [4].

There is a slight predilection for the male population compared to the females due to the decreasing incidence of cardiogenic and neurogenic inciting events among females. In neurogenic pulmonary edema, more than half of patients have sustained a blunt trauma to the head with concussion. More than 71% of patient fatalities with subarachnoid hemorrhage complicates with neurogenic pulmonary edema. In at least of a third of the patients with status epilepticus develop neurogenic pulmonary edema [5].

Sex distribution

Age distribution

Pathophysiology

The accumulation of the fluid within the alveoli is commonly brought about by cardiogenic causes. In the normal flow of blood, the atria receives the blood from the lungs where it is pumped outward by the left ventricle to the other organs of the body. Any pathology that endangers this balance and causes an increased pressure in the atria can cause a backflow of fluids to the air sacs due to the increased in ventricular and atrial pressure. Heart related pathologies that results in cardiogenic pulmonary edema include coronary artery diseases, cardiomyopathy, hypertension, and cardiac valvular problems. In non-cardiogenic pulmonary edema however, the capillaries within the lungs become more permeable or “leaky” due to inflammatory responses with infection, bleeding, and pressure. This are usually brought about by toxins, medications, contrast media [6], viral infections, barotrauma, near drowning, and neurogenic disorders.

Prevention

The active control of the congestive heart failure is paramount in the prevention of the hydrostatic pulmonary edema. Lung infections like pneumonia must be treated promptly and monitored to prevent progressive accumulation of fluids within the lung spaces. Adequate acclimatization should be in place for high altitude athletes to prevent the occurrence of pulmonary edema. A preventive dose of the corticosteroid dexamethasone may avert the progression to pulmonary edema of patients diagnosed with pulmonary hypertension and barotrauma [10].

Summary

Pulmonary edema is a medical condition wherein there is an excessive fluid in the pulmonary space. The accumulating fluid in the lungs fills in the air sacs and manifest externally as dyspnea. Pulmonary edema is most commonly caused by heart failure although some non-cardiac causes like pulmonary infections, reactions to medications, external trauma, barotrauma from high altitudes, and toxins may predispose patients to this serious lung disorder. Pulmonary edema which occurs acutely is considered a serious medical emergency that could be potentially fatal if not treated immediately.

Patient Information

Definition

Pulmonary edema is a medical condition wherein there is an abnormal accumulation of fluid (exudates) in the alveoli. The accumulation of fluids in the lungs fill in the air sacs and manifest externally dyspnea, chest pain, and cyanosis.

Cause

The majority of cases of pulmonary edema are caused by cardiogenic factors like congestive heart failure, cardiomyopathy and valvular diseases. Non-cardiogenic causes include pneumonia, toxins, medications, and barotrauma.

Symptoms

Patients usually present with dyspnea, chest pain, signs of cyanosis, productive cough of red tinged sputum, and severe anxiety with restlessness.

Diagnosis

Preliminary physical examination, ECG and Chest X-ray are routinely done in an emergency setting for patients suspected of pulmonary edema. Additional tests like pulse oximetry, blood tests, echocardiography, and pulmonary/cardiac catheterization are performed as soon as the patients are stabilized.

Treatment and follow-up

Oxygen inhalation is the primary intervention given to patients with pulmonary edema. Cardiogenic pulmonary edema patients are given preload unloaders and afterload reducers to allay the cardiogenic instability. Morphine may also be given to relieve the chest pain and severe anxiety in patients.

References

Article

Muroi C, Keller M, Pangalu A, Fortunati M, Yonekawa Y, Keller E. Neurogenic pulmonary edema in patients with subarachnoid hemorrhage. J Neurosurg Anesthesiol. Jul 2008; 20(3):188-92.
Baumann A, Audibert G, McDonnell J, Mertes PM. Neurogenic pulmonary edema. Acta Anaesthesiol Scand. Apr 2007; 51(4):447-55.
Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and survival with heart failure. N Engl J Med 2002; 347:1397–402.
Lloyd-Jones DM, Larson MG, Leip EP, et al. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation 2002; 106:3068–72.
Reuter-Rice K, Duthie S, Hamrick J. Neurogenic pulmonary edema associated with pediatric status epilepticus. Pediatr Emerg Care. Oct 2011; 27(10):957-8.
Demirhan A, Yasar Tekelioglu U, Akkaya A, Dagistan E, Suzi Ayhan S, Ozturk S. Magnetic resonance imaging contrast agent related pulmonary edema: a case report. Eur Rev Med Pharmacol Sci. Oct 2012; 16 Suppl 4:110-2.
Lloyd-Jones DM. The risk of congestive heart failure: sobering lessons from the Framingham Heart Study. Curr Cardiol Rep 2001; 3:184–90.
Piazza O, Venditto A, Tufano R. Neurogenic pulmonary edema in subarachnoid hemorrage. Panminerva Med. Sep 2011; 53(3):203-10.
LHer E, Duquesne F, Girou E, de Rosiere XD, Le Conte P, Renault S, et al. Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients. Intensive Care Med. May 2004; 30(5):882-8.
Perimenis P. Sildenafil for the treatment of altitude-induced hypoxaemia. Expert Opin Pharmacother 2005 6 (5): 835–7.

Symptoms

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