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pulmonary edema (pulmonary congestion, PE)

- Pulmonary edema (PE) is a condition, usually acute, but sometimes chronic, where fluid builds up in the lungs. - This often occurs as a response to left ventricular failure in ischemic heart disease, hypertension, or aortic valve disease (cardiogenic pulmonary edema). Etiology: 1) imbalance of Starling forces a) left ventricular failure b) obstruction of flow through the mitral valve - mitral stenosis - atrial myxoma d) pulmonary veno-occlusive disease (rare) e) pulmonary artery hypertension (overperfusion PE) f) hypoalbuminemia g) asthma 2) altered alveolar-capillary membrane permeability, adult respiratory distress syndrome (ARDS) a) infectious pneumonia b) inhaled toxins c) circulating vascular toxins - snake venom - bacterial endotoxin d) aspiration of acidic gastric acid contents e) acute radiation pneumonitis f) endogenous vasoactive substances (histamines, kinins) g) disseminated intravascular coagulation h) hypersensitivity pneumonitis i) shock in associated with non-thoracic trauma j) acute hemorrhagic pancreatitis 3) lymphatic insufficiency a) post lung transplantation b) lymphangtic carcinomatosis c) fibrosing lymphangitis (silicosis) 4) poorly understood causes a) high-altitude pulmonary edema b) neurogenic pulmonary edema c) pulmonary embolism d) eclampsia e) post cardioversion f) post anesthesia g) post cardiopulmonary bypass 5) pharmacologic causes: a) contrast media b) opiates - heroin - methadone - morphine - propoxyphene c) nitrofurantoin d) propoxyphene e) non-steroidal anti-inflammatory drugs (NSAIDs) - aspirin - phenylbutazone - oxyphenbutazone f) leukoagglutinins in blood products g) chlordiazepoxide (Librium) h) ethchlorvynol (Placidyl) i) interleukin-2 Pathology: 1) pulmonary capillary pressure exceeds forces which maintain fluid in the intravascular space: a) serum oncotic pressure b) interstitial hydrostatic pressure 2) altered alveolar-capillary membrane permeability 3) accumulation of fluid in the pulmonary interstitium a) leakage of fluid into alveolar space b) impairment of gas exchange Laboratory: - serum BNP [8] - serum troponin-I (serial) Special laboratory: - electrocardiogram [8] Radiology: - chest X-ray - point of care ultrasound outperforms chest X-ray [6] - echocardiogram [8] Management: - non-invasive positive pressure ventilation reduces mortality & need for endotracheal intubation [7] - see cardiogenic pulmonary edema

Specific

cardiogenic pulmonary edema (CPE) high-altitude pulmonary edema

General

edema (swelling, tumefaction, tumescence) lung disease

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 130
  2. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 761, 762, 763
  4. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 173
  5. Hubble MW et al, Effectiveness of prehospital continuous positive airway pressure in the management of acute pulmonary edema. Prehosp Emerg Care 2006, 10:430 PMID: 16997770
  6. Raja AS Point-of-Care Ultrasound Can Be Used to Evaluate for Acute Pulmonary Edema NEJM Journal Watch. Sept 4, 2014 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Al Deeb M et al. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: A systematic review and meta-analysis. Acad Emerg Med 2014 Aug; 21:843 PMID: 25176151
  7. The NNT: Non-Invasive Positive Pressure Ventilation for Acute Pulmonary Edema. http://www.thennt.com/nnt/non-invasive-positive-pressure-ventilation-for-pulmonary-edema/ - Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013 May 31;5:CD005351 PMID: 23728654 - 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
  8. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018.