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PulmonaryedemaWikipedia

Pulmonaryedema
FromWikipedia,thefreeencyclopedia

Pulmonaryedemaisfluidaccumulationinthetissueandairspacesofthelungs.[1]Itleadstoimpairedgas
exchangeandmaycauserespiratoryfailure.Itisduetoeitherfailureoftheleftventricleoftheheartto
adequatelyremovebloodfromthepulmonarycirculation("cardiogenicpulmonaryedema"),oraninjurytothe
lungparenchymaorvasculatureofthelung("noncardiogenicpulmonaryedema").[2]Treatmentisfocusedon
threeaspects:firstlyimprovingrespiratoryfunction,secondly,treatingtheunderlyingcause,andthirdly
avoidingfurtherdamagetothelung.Pulmonaryedema,especiallyacute,canleadtofatalrespiratorydistressor
cardiacarrestduetohypoxia.Itisacardinalfeatureofcongestiveheartfailure.ThetermisfromtheGreek
.

Pulmonaryedema
pulmonaryoedema

Contents
1 Signsandsymptoms
2 Causes
2.1 Cardiogenic
2.2 Noncardiogenic
2.3 Other
3 Diagnosis
4 Prevention
5 Management
5.1 Cardiogenicpulmonaryedema
6 References
7 Externallinks

Signsandsymptoms
Theoverwhelmingsymptomofpulmonaryedemaisdifficultybreathing,butmayalsoincludesymptomssuch
ascoughingupblood(classicallyseenaspink,frothysputum),excessivesweating,anxiety,andpaleskin.
Shortnessofbreathcanmanifestasorthopnea(inabilitytoliedownflatduetobreathlessness)and/or
paroxysmalnocturnaldyspnea(episodesofseveresuddenbreathlessnessatnight).Thesearecommon
presentingsymptomsofchronicpulmonaryedemaduetoleftventricularfailure.Thedevelopmentof
https://en.wikipedia.org/wiki/Pulmonary_edema

Pulmonaryedemawithsmallpleuraleffusionson
bothsides.
Classificationandexternalresources
Specialty

Cardiology,criticalcaremedicine

ICD10

J81(http://apps.who.int/classifications/
icd10/browse/2016/en#/J81)

ICD9CM

514(http://www.icd9data.com/getICD
9Code.ashx?icd9=514)518.4(http://w
ww.icd9data.com/getICD9Code.ashx?i
cd9=518.4)

DiseasesDB 11017(http://www.diseasesdatabase.co
m/ddb11017.htm)
MedlinePlus 000140(http://www.nlm.nih.gov/medl
ineplus/ency/article/000140.htm)
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pulmonaryedemamaybeassociatedwithsymptomsandsignsof"fluidoverload"thisisanonspecifictermto
describethemanifestationsofleftventricularfailureontherestofthebodyandincludesperipheraledema
(swellingofthelegs,ingeneral,ofthe"pitting"variety,whereintheskinisslowtoreturntonormalwhen
pressedupon),raisedjugularvenouspressureandhepatomegaly,wheretheliverisenlargedandmaybetender
orevenpulsatile.Othersignsincludeendinspiratorycrackles(soundsheardattheendofadeepbreath)on
auscultationandthepresenceofathirdheartsound.[2]

eMedicine

Causes

MeSH

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ape.com/article/157452overview)
article/300813(http://emedicine.medsc
ape.com/article/300813overview),
article/360932(http://emedicine.medsc
ape.com/article/360932overview)
D011654(https://www.nlm.nih.gov/cg
i/mesh/2016/MB_cgi?field=uid&term
=D011654)

Pulmonaryedemaisanaccumulationoffluidwithintheparenchymaandairspacesofthelungs.Classicallyit
iscardiogenic(leftventricular)butfluidmayalsoaccumulateduetodamagetothelung.Thisdamagemaybe
directinjuryorinjurymediatedbyhighpressureswithinthepulmonarycirculation.Whendirectlyorindirectlycausedbyincreasedleftventricularpressure
pulmonaryedemamayformwhenmeanpulmonarypressurerisesfromthenormalof15mmHg[3]toabove25mmHg.[4]Broadly,thecausesofpulmonaryedema
canbedividedintocardiogenicandnoncardiogenic.Byconventioncardiogenicreferstoleftventricularcauses.

Cardiogenic
Congestiveheartfailurewhichisduetotheheart'sinabilitytopumpthebloodoutofthepulmonarycirculationatasufficientrateresultinginelevationin
wedgepressureandpulmonaryedemathismaybeduetoleftventricularfailure,arrhythmias,orfluidoverload,e.g.,fromkidneyfailureorintravenous
therapy.
Hypertensivecrisiscancausepulmonaryedemaastheelevationinbloodpressureandincreasedafterloadontheleftventriclehindersforwardflowand
causestheelevationinwedgepressureandsubsequentpulmonaryedema.

Noncardiogenic
Negativepressurepulmonaryedema[5]inwhichasignificantnegativepressureinthechest(suchasfromaninhalationagainstanupperairwayobstruction)
rupturescapillariesandfloodsthealveoli.
Neurogeniccauses[6](seizures,headtrauma,strangulation,electrocution).
Acuterespiratorydistresssyndrome[7]

Other
Injurytothelungmayalsocausepulmonaryedemathroughinjurytothevasculatureandparenchymaofthelung.Theacutelunginjuryacuterespiratorydistress
syndrome(ALIARDS)coversmanyofthesecauses,buttheymayinclude:
Inhalationofhotortoxicgases
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Pulmonarycontusion,i.e.,highenergytrauma(e.g.vehicleaccidents)
Aspiration,e.g.,gastricfluid
Reexpansion,i.e.postlargevolumethoracocentesis,resolutionofpneumothorax,postdecortication,removalofendobronchialobstruction,effectivelya
formofnegativepressurepulmonaryoedema.
Reperfusioninjury,i.e.postpulmonarythromboendartectomyorlungtransplantation
Swimminginducedpulmonaryedemaalsoknownasimmersionpulmonaryedema[8][9]
Multiplebloodtransfusions
Severeinfectionorinflammationwhichmaybelocalorsystemic.ThisistheclassicalformofALIARDS.
Somecausesofpulmonaryedemaarelesswellcharacterisedandarguablyrepresentspecificinstancesofthebroaderclassificationsabove.
Arteriovenousmalformation
Hantaviruspulmonarysyndrome
Highaltitudepulmonaryedema(HAPE)[10][11]
Envenomation,suchaswiththevenomofAtraxrobustus[12]
Flashpulmonaryedema

Diagnosis
Thereisnoonesingletestforconfirmingthatbreathlessnessiscausedbypulmonaryedemaindeed,inmanycases,the
causeofshortnessofbreathisprobablymultifactorial.
Lowoxygensaturationanddisturbedarterialbloodgasreadingssupporttheproposeddiagnosisbysuggestingapulmonary
shunt.ChestXraywillshowfluidinthealveolarwalls,KerleyBlines,increasedvascularshadowinginaclassical
batwingperihilumpattern,upperlobediversion(increasedbloodflowtothesuperiorpartsofthelung),andpossibly
pleuraleffusions.Incontrast,patchyalveolarinfiltratesaremoretypicallyassociatedwithnoncardiogenicedema[2]
Lungultrasound,employedbyahealthcareprovideratthepointofcare,isalsoausefultooltodiagnosepulmonaryedema
notonlyisitaccurate,butitmayquantifythedegreeoflungwater,trackchangesovertime,anddifferentiatebetween
cardiogenicandnoncardiogenicedema.[13]
Especiallyinthecaseofcardiogenicpulmonaryedema,urgentechocardiographymaystrengthenthediagnosisby
demonstratingimpairedleftventricularfunction,highcentralvenouspressuresandhighpulmonaryarterypressures.

XRayshowingpulmonaryoedema

Bloodtestsareperformedforelectrolytes(sodium,potassium)andmarkersofrenalfunction(creatinine,urea).Liverenzymes,inflammatorymarkers(usuallyC
reactiveprotein)andacompletebloodcountaswellascoagulationstudies(PT,aPTT)arealsotypicallyrequested.Btypenatriureticpeptide(BNP)isavailablein
manyhospitals,sometimesevenasapointofcaretest.LowlevelsofBNP(<100pg/ml)suggestacardiaccauseisunlikely.[2]
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Prevention
Inthosewithunderlyingheartdisease,effectivecontrolofcongestivesymptomspreventspulmonaryedema.
Dexamethasoneisinwidespreaduseforthepreventionofhighaltitudepulmonaryedema.Sildenafilisusedasapreventive
treatmentforaltitudeinducedpulmonaryedemaandpulmonaryhypertension,[14][15]themechanismofactionisvia
phosphodiesteraseinhibitionwhichraisescGMP,resultinginpulmonaryarterialvasodilationandinhibitionofsmooth
musclecellproliferation.[16]Whilethiseffecthasonlyrecentlybeendiscovered,sildenafilisalreadybecominganaccepted
treatmentforthiscondition,inparticularinsituationswherethestandardtreatmentofrapiddescenthasbeendelayedfor
somereason.[17]

Management

PulmonaryedemaonCTscan
(coronalMPR)

Theinitialmanagementofpulmonaryedema,irrespectiveofthetypeorcause,issupportingvitalfunctions.Therefore,if
thelevelofconsciousnessisdecreaseditmayberequiredtoproceedtotrachealintubationandmechanicalventilationtopreventairwaycompromise.Hypoxia
(abnormallylowoxygenlevels)mayrequiresupplementaryoxygen,butifthisisinsufficientthenagainmechanicalventilationmayberequiredtoprevent
complications.Treatmentoftheunderlyingcauseisthenextprioritypulmonaryedemasecondarytoinfection,forinstance,wouldrequiretheadministrationof
appropriateantibiotics.

Cardiogenicpulmonaryedema
Acutecardiogenicpulmonaryedemaoftenrespondsrapidlytomedicaltreatment.[18]Positioninguprightmayrelievesymptoms.Loopdiureticssuchasfurosemide
orbumetanideareadministered,oftentogetherwithmorphineordiamorphinetoreducerespiratorydistress.[18]Bothdiureticsandmorphinemayhavevasodilator
effects,butspecificvasodilatorsmaybeused(particularlyintravenousglyceryltrinitrateorISDN)providedthebloodpressureisadequate.[18]
Continuouspositiveairwaypressureandbilevelpositiveairwaypressure(BIPAP/NIPPV)hasbeendemonstratedtoreducetheneedofmechanicalventilationin
peoplewithseverecardiogenicpulmonaryedema,andmayreducemortality.[19]
Itispossibleforcardiogenicpulmonaryedematooccurtogetherwithcardiogenicshock,inwhichthecardiacoutputisinsufficienttosustainanadequateblood
pressure.Thiscanbetreatedwithinotropicagentsorbyintraaorticballoonpump,butthisisregardedastemporarytreatmentwhiletheunderlyingcauseis
addressed.[18]

References
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1."pulmonaryedema(http://web.archive.org/web/20090616022448/http://www.merck
source.com/pp/us/cns/cns_hl_dorlands_split.jsp?pg=/ppdocs/us/common/dorlands/
dorland/three/000033856.htm)"atDorland'sMedicalDictionary
2.WareLB,MatthayMA(December2005)."Clinicalpractice.Acutepulmonary
edema".N.Engl.J.Med.353(26):278896.doi:10.1056/NEJMcp052699.
PMID16382065.
3.WhatIsPulmonaryHypertension?(http://www.nhlbi.nih.gov/health/dci/Diseases/p
ah/pah_what.html)FromDiseasesandConditionsIndex(DCI).NationalHeart,
Lung,andBloodInstitute.LastupdatedSeptember2008.Retrievedon6April
2009.
4.Chapter41,page210in:Cardiologysecrets(https://books.google.com/books?id=I
YFAsxAUA_MC&printsec=frontcover#PPR3,M1)ByOliviaVynnAdairEdition:
2,illustratedPublishedbyElsevierHealthSciences,2001ISBN1560534206,
ISBN9781560534204
5.Papaioannou,V.Terzi,I.Dragoumanis,C.Pneumatikos,I.(2009)."Negative
pressureacutetracheobronchialhemorrhageandpulmonaryedema".Journalof
Anesthesia.23(3):417420.doi:10.1007/s0054000907570.
6.O'Leary,R.McKinlay,J.(2011)."Neurogenicpulmonaryoedema".Continuing
EducationinAnaesthesia,CriticalCare&Pain.11(3):8792.
doi:10.1093/bjaceaccp/mkr006.
7.Boyle,AJMacSweeney,RMcAuley,DF(August2013)."Pharmacological
treatmentsinARDSastateoftheartupdate".BMCMed.11:166.
doi:10.1186/1741701511166.PMC3765621 .PMID23957905.
8.HampsonNB,DunfordRG(1997)."Pulmonaryedemaofscubadivers".Undersea
HyperbMed.24(1):2933.PMID9068153.Retrieved20080904.
9.CochardG,ArvieuxJ,LacourJM,MadouasG,MongredienH,ArvieuxCC
(2005)."Pulmonaryedemainscubadivers:recurrenceandfataloutcome".
UnderseaHyperbMed.32(1):3944.PMID15796313.Retrieved20080904.
10.LuksAM(2008)."Dowehavea"bestpractice"fortreatinghighaltitude
pulmonaryedema?".HighAlt.Med.Biol.9(2):1114.
doi:10.1089/ham.2008.1017.PMID18578641.

11.Bates,M(2007)."Highaltitudepulmonaryedema".AltitudePhysiology
Expeditions.Retrieved20080904.
12.WhiteJ,GrayM,FisherM(1989).AtraxRobustus(http://www.inchem.org/docu
ments/pims/animal/atrax.htm)IPCSInChem
13.Volpicelli,GiovanniElbarbary,MahmoudBlaivas,MichaelLichtenstein,Daniel
A.Mathis,GebhardKirkpatrick,AndrewW.Melniker,LawrenceGargani,
LunaNoble,VickiE.(20120401)."Internationalevidencebased
recommendationsforpointofcarelungultrasound".IntensiveCareMedicine.38
(4):577591.doi:10.1007/s0013401225134.ISSN14321238.
PMID22392031.
14.RichaletJP,GratadourP,RobachP,etal.(2005)."Sildenafilinhibitsaltitude
inducedhypoxemiaandpulmonaryhypertension".Am.J.Respir.Crit.CareMed.
171(3):27581.doi:10.1164/rccm.200406804OC.PMID15516532.
15.PerimenisP(2005)."Sildenafilforthetreatmentofaltitudeinducedhypoxaemia".
ExpertOpinPharmacother.6(5):8357.doi:10.1517/14656566.6.5.835.
PMID15934909.
16.Clark,MichaelKumar,ParveenJ.(2009).KumarandClark'sclinicalmedicine.
St.Louis,Mo:ElsevierSaunders.p.783.ISBN0702029939.
17.FagenholzPJ,GutmanJA,MurrayAF,HarrisNS(2007)."Treatmentofhigh
altitudepulmonaryedemaat4240minNepal".HighAlt.Med.Biol.8(2):139
46.doi:10.1089/ham.2007.3055.PMID17584008.
18.ClelandJG,YassinAS,KhadjooiK(2010)."Acuteheartfailure:focusingonacute
cardiogenicpulmonaryoedema".ClinMed.10(1):5964.
doi:10.7861/clinmedicine.10159.PMID20408310.
19.VitalFM,LadeiraMT,AtallahAN(2013)."Noninvasivepositivepressure
ventilation(CPAPorbilevelNPPV)forcardiogenicpulmonaryoedema".
CochraneDatabaseSystRev.5:CD005351.
doi:10.1002/14651858.CD005351.pub3.PMID23728654.

Externallinks
HeartFailureMatters.org(http://www.heartfailurematters.org/en_GB#journey)AnimationshowingHowHeartFailurecausesFluidAccumulationCreated
bytheEuropeanHeartFailureAssociation
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