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cardiogenic pulmonary edema (CPE)

Etiology: 1) left ventricular failure (congestive heart failure) 2) obstruction of flow through the mitral valve a) mitral stenosis b) atrial myxoma === Precipitating factors: === 1) severe hypertension 2) myocardial ischemia or infarction 3) acute mitral regurgitation 4) new onset arrhythmias a) tachyarrhythmia b) bradyarrhythmia 5) volume overload in the setting of left ventricular dysfunction 6) correction of precipitating event may be necessary for resolution of pulmonary edema Pathology: (see pulmonary edema) Clinical manifestations: 1) symptoms: a) usually rapid in onset b) dyspnea c) air hunger d) anxiety e) restlessness 2) signs a) decreased peripheral perfusion b) pulmonary congestion c) use of accessory respiratory muscles d) wheezes e) expectoration of pink, frothy fluid f) cardiomegaly g) third heart sound (S3) Laboratory: - serum BNP elevation more accurate than emergency physician [2] Special laboratory: - pulmonary artery catheter for pulmonary capillary pressure a) facilitates differentiation of cardiogenic vs. other cause of pulmonary edema b) allows hemodynamic monitoring during therapy Radiography: 1) cardiomegaly 2) interstitial & perihilar vascular engorgement 3) Kerly B lines 4) pleural effusion 5) radiographic changes may lag behind development of symptoms 6) resolution of radiographic changes may not coincide with clinical improvement Management: 1) Supportive therapy a) oxygen - SaO2 > 88% - pO2 > 60 torr b) non-invasive positive pressure ventilation [5,7] - CPAP & non-invasive pressure support ventilation reduce hypoxemia, mortality & need for endotracheal intubation [3,4,6,7] - BiPAP may be better c) mechanical ventilation - hypercapnia - inadequate oxygenation on non-rebreathing face mask d) sitting position - improves pulmonary function - assists venous pooling e) reduce cardiac workload - bedrest - treat pain - treat anxiety 2) Pharmacologic therapy a) morphine - reduces anxiety - dilates pulmonary & systemic veins - 2-5 mg IV every 10-25 min - naloxone should be available for respiratory depression - administer morphine before diuretic - other opiates are less effective b) diuresis, furosemide - venodilator - decreases pulmonary congestion within minutes of IV infusion - begin 20-40 mg IV - increase for response up to 200 mg IV c) nitroglycerin - venodilator - may potentiate effect of furosemide - begin 5 ug/min, titrate to effect d) inotropic agents - may be useful as secondary agents - dobutamine e) vasodilator agent for afterload reduction - ACE inhibitor, ARB - hydralazine - phosphodiesterase inhibitors 3) Mechanical reduction of pulmonary congestion a) hemodialysis b) ultrafiltration c) phlebotomy d) rotating tourniquets to reduce venous return 4) Correction of precipitating factors

Related

atrial myxoma left ventricular failure mitral stenosis (MS)

General

pulmonary edema (pulmonary congestion, PE)

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 130-31
  2. Ray P, Arthaud M, Birolleau S, Isnard R, Lefort Y, Boddaert J, Riou B; the EPIDASA Study Group. Comparison of brain natriuretic Peptide and probrain natriuretic Peptide in the diagnosis of cardiogenic pulmonary edema in patients aged 65 and older. J Am Geriatr Soc. 2005 Apr;53(4):643-8. PMID: 15817011
  3. Masip J et al, Noninvasive ventilation in acute cardiogenic pulmonary edema: Systematic review and meta-analysis. JAMA 2005 Dec 28; 294:3124-30. PMID: 16380593
  4. Peter JV et al, Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: A meta-analysis Lancet 2006; 367:1155 PMID: 16616558
  5. Medical Knowledge Self Assessment Program (MKSAP) 14, 17, 19 American College of Physicians, Philadelphia 2006, 2015, 2022
  6. The NNT: Non-Invasive Positive Pressure Ventilation for Acute Pulmonary Edema. http://www.thennt.com/nnt/non-invasive-positive-pressure-ventilation-for-pulmonary-edema/ - Masip J, Roque M, Sanchez B et al Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA. 2005 Dec 28;294(24):3124-30. PMID: 16380593
  7. Berbenetz N, Wang Y, Brown J et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev 2019 Apr 5; 4:CD005351. PMID: 30950507 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005351.pub4/full