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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.


Presentation

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

Fatigue
  • You may experience: shortness of breath, chest discomfort, heart palpitations, coughing, difficulty walking uphill, fatigue, fever, or headaches.[lungmds.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]
  • […] 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[symptoma.com]
Cough
  • This case describes a patient with no prior history of HAPE and extensive experience hiking above 2,500 meters who developed progressive dyspnea and cough while ascending to 3,200 meters.[ncbi.nlm.nih.gov]
  • Associated symptoms included cough, weakness, expectoration of froth, chest discomfort, orthopnea, wheezing, hemoptysis, and dizziness.[archive.rubicon-foundation.org]
  • Tachycardia Orthopnea Distended Jugular veins Noisy, wet respirations that do not clear with coughing. Cough with Frothy, blood-tinged sputum. 7.[slideshare.net]
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]
  • High altitude pulmonary edema (HAPE) is a form of high altitude illness characterized by cough, dyspnea upon exertion progressing to dyspnea at rest and eventual death, seen in patients who ascend over 2,500 meters, particularly if that ascent is rapid[ncbi.nlm.nih.gov]
Pneumonia
  • Five patients (42%) developed pneumonia, and we postponed extubation until recovery from pneumonia. The cause for severe disability and death was symptomatic vasospasm and primary brain damage. No patients had rebleeding from ruptured aneurysms.[ncbi.nlm.nih.gov]
  • While both pulmonary edema and pneumonia cause a form of buildup in the lungs, the former is primarily caused by CHF. Pneumonia, on the other hand, is caused by an infection.[healthline.com]
Rales
  • However, the patient developed pink frothy sputum with diffuse bilateral rales 30 min later after transported to surgical intensive care unit (SICU). Negative pressure pulmonary edema.[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.[doi.org]
Tachypnea
  • Six hours after pleural fluid drainage, the patient developed a nonproductive cough, mild tachypnea, shortness of breath, and low oxygen saturation (88%). His chest radiograph showed diffuse heterogeneous opacities in the right hemithorax.[ncbi.nlm.nih.gov]
  • Hypoxemia at this stage is rarely of sufficient magnitude to stimulate tachypnea.[emedicine.com]
Heart Disease
  • KEYWORDS: Cesarean section; Chest ultrasound; Spinal anaesthesia; Valvular heart disease[ncbi.nlm.nih.gov]
  • 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]
Tachycardia
  • 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]
Hypotension
  • However, its use continues to be controversial due to concerns of drug induced hypotension, syncope or paresthesia.[ncbi.nlm.nih.gov]
  • Hypotension - the triad of hypotension (systolic blood pressure cardiogenic shock. In hypertensive heart failure, a high blood pressure, tachycardia and vasoconstriction present with signs of pulmonary oedema without extensive systemic congestion.[patient.info]
  • […] has peripheral vasodilatory effects that can result in worsening hypotension, which may require management with a vasopressor.[nps.org.au]
  • Precipitous hypotension is hard to reverse, so use is best reserved for longer term management of HF.[lifeinthefastlane.com]
Cyanosis
  • The accumulation of fluids in the lungs fill in the air sacs and manifest externally dyspnea, chest pain, and cyanosis.[symptoma.com]
  • 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]
  • (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]
  • 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]
Palpitations
  • 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]
  • […] drowning that worsens when lying down Wheezing or gasping for breath Cold, clammy skin Anxiety, restlessness or a sense of apprehension A cough that produces frothy sputum that may be tinged with blood Blue-tinged lips A rapid, irregular heartbeat (palpitations[mayoclinic.org]
  • You may experience: shortness of breath, chest discomfort, heart palpitations, coughing, difficulty walking uphill, fatigue, fever, or headaches.[lungmds.com]
  • […] 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]
  • ACS SOB Cough pink frothy sputum Dry cough Green sputum Haemoptysis Chest pain Palpitations Fever Sweating Acuity Nocturnal (ii) Clinical examination (see Box 1 and Table 2) Box 1: Typical examination findings in a patient with acute pulmonary oedema[rcemlearning.co.uk]
Headache
  • We present a case of a 31-year-old Caucasian woman with a history of hypertension and recurrent occipital headaches who was admitted to the emergency department due to severe de novo AHF presenting as pulmonary edema and cardiogenic shock.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • A severe headache, vomiting and lethargy will progress to unsteadiness, confusion, drowsiness and ultimately coma. HACE can kill in only a few hours.[altitude.org]
  • Assess for signs of hypoxia: restlessness, confusion, headache. 22. Monitor ECG for dysrrhythmia development that may be related to hypoxemia, acid-base imbalance, or ventricular irritability.[slideshare.net]
Dizziness
  • Associated symptoms included cough, weakness, expectoration of froth, chest discomfort, orthopnea, wheezing, hemoptysis, and dizziness.[ncbi.nlm.nih.gov]
  • […] 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]
  • […] 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]
  • 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]
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]
  • 38.3 Â C 100 - 100.9 Â F 10 Points 38.4 - 38.8 Â C 101 - 101.9 Â F 15 Punkte 38.9 - 39.4 Â C 102 - 102.9 Â F 20 Points 39.5 - 39.9 Â C 103 - 103.9 Â F 25 Points 40 Â C 104 Â F 30 Points 2.2 Central Nervous Effects Symptoms Points Missing 0 Points Mild (agitation[flexikon.doccheck.com]
  • In acute pulmonary edema, the patient may be extremely fearful or agitated. Breathlessness, dizziness, and faintness are common complaints.[tele.med.ru]
  • 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]
Oliguria
  • It was interesting to note that oliguria persisted in Case 2 after 500 mg frusemide when there was a mean pulmonary capillary wedge pressure (PCWP) of 13 cm H2O but following subsequent elevation of the PCWP to 16 cm H2O with plasma there was an immediate[inchem.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
Pulmonary Infiltrate
  • The patient underwent bronchoscopy with destruction of the tumor obstructing the left main pulmonary bronchus, resulting in clinical improvement and resolution of the right pulmonary infiltrates.[ncbi.nlm.nih.gov]
  • A chest radiograph shows bilateral pulmonary infiltrates consistent with pulmonary edema and borderline enlargement of the cardiac silhouette.[doi.org]
Kerley B Lines
  • The early signs of pulmonary edema (interstitial edema) are the septal lines (Kerley B lines), which are horizontal lines seen laterally in the lower zones.[emedicine.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]
  • 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]
  • 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]
Bilateral Pulmonary Infiltrate
  • A chest radiograph shows bilateral pulmonary infiltrates consistent with pulmonary edema and borderline enlargement of the cardiac silhouette.[doi.org]
Atelectasis
  • The anesthesiologists should determine appropriate anesthetic regimens according to the examination results to avoid acute atelectasis and postoperative pulmonary edema.[ncbi.nlm.nih.gov]
  • Lung consolidations may have a variety of causes including infection, pulmonary embolism, lung cancer and metastasis, compression atelectasis, obstructive atelectasis, and lung contusion.[doi.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]
Pulmonary Arterial Pressure Increased
  • Systolic pulmonary artery pressure increased at high altitude, but normalised with sildenafil. The altitude-induced decrease in maximal O 2 consumption was significantly smaller with sildenafil than with placebo.[doi.org]
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]
  • Care is required when giving oxygen if the patient has lung disease as oxygen can reduce respiratory drive causing hypercapnia (respiratory failure).[doi.org]
  • Monitor ABG results for presence of hypoxemia(decrease PaO2) and hypercapnia(Increase PcO2) 21. Assess for signs of hypoxia: restlessness, confusion, headache. 22.[slideshare.net]
  • 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]

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:

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

  1. 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.
  2. Baumann A, Audibert G, McDonnell J, Mertes PM. Neurogenic pulmonary edema. Acta Anaesthesiol Scand. Apr 2007; 51(4):447-55.
  3. 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.
  4. 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.
  5. Reuter-Rice K, Duthie S, Hamrick J. Neurogenic pulmonary edema associated with pediatric status epilepticus. Pediatr Emerg Care. Oct 2011; 27(10):957-8.
  6. 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.
  7. Lloyd-Jones DM. The risk of congestive heart failure: sobering lessons from the Framingham Heart Study. Curr Cardiol Rep 2001; 3:184–90.
  8. Piazza O, Venditto A, Tufano R. Neurogenic pulmonary edema in subarachnoid hemorrage. Panminerva Med. Sep 2011; 53(3):203-10.
  9. 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.
  10. Perimenis P. Sildenafil for the treatment of altitude-induced hypoxaemia. Expert Opin Pharmacother 2005 6 (5): 835–7. 

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Last updated: 2019-07-11 21:50