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Definition
Epidemiology
Pathophysiology
Classifications & causes
Pathogenesis
Staging
Clinical manifestations
Complications
Differential diagnosis
Treatment
Definition
is a condition
Pulmonary Edema ;
characterized by fluid accumulation in
the lungs caused by extravasation of
fluid from pulmonary vasculature in to
the interstitium and alveoli of the lungs
The extent to which fluid accumulates in the interstitium of the lung
depends on the balance of hydrostatic and oncotic forces within
the pulmonary capillaries and in the surrounding tissue.
Hydrostatic pressure
-favors movement of fluid from the capillary into the interstitium
Oncotic pressure
-favors movement of fluid into the vessel
Maintenance
-lymphatic in the tissue carry away the small amounts of protein
that may leak out
-tight junction of endothelium are impermeable to protein
Epidemiology
Pulmonary edema occurs in about 1% to 2% of the general
population.
Basic pathophysiology:
Accumulation of fluid
`
Pulmonary edema
Risk Factors
Vary by cause
Increased alveolar–capillary
membrane permeability
Decreased plasma oncotic
pressure
Increased negativity of
pulmonary interstitial pressure
Lymphatic insufficiency or
obstruction
Non- cardiogenic PE
cause
I. Direct injury to the lung
II. Hematogenous injury to the
lung
III. possible lung injury plus
elevated hydrostatic pressure
Staging of PE
This directs blood flow away from hypoxic areas of lung towards area
that are well oxygenated
Long term(chronic)
Paraxosomal nocturnal dyspnea
orthopnea
Rapid weight gain
Loss of appetite
fatigue
ankle and leg swelling
Signs
Tachycardia
Tachypnea
Confusion
Agitation
Anxious
Diaphoric
Hypertension
Cool extremities
Rales
Wheezing
CVS findings ; S3 ,accentuation of pulmonic
component of S2, jugular venous distention…..
Special considerations
leg swelling(edema),
abdominal swelling(ascites),
Pleural effusion,
Congestion & swelling of liver,
acute heart attack (myocardial infarction [MI]),
cardiogenic shock,
arrhythmias,
electrolyte disturbances,
mesenteric insufficiency,
protein enteropathy,
respiratory arrest, and death.
Differential diagnosis
Pneumothorax
Bronchitis
Cardiac tamponed
COPD
Pericarditis
Pneumonia (bacterial ,viral , PCP)
Pulmonary embolism
Shocks (cardiogenic ,septic ,anaphylactic)
Venous air embolism
Distinguishing Cardiogenic from
Non-cardiogenic Pulmonary Edema
Finding suggesting cardiogenic edema
-S3 gallop
-elevated JVP
-Peripheral edema
Findings suggesting non-cardiogenic
edema
-Pulmonary findings may be relatively normal
in the early stages
-.
Distinguishing …..
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 cause
-Heart size is normal
-Uniform alveolar infiltrate
-pleural effusion is uncommon
-lack of cephalization
Distinguishing…..
Hypoxemia
Cardiogenic
- due to ventilation perfusion miss match
-respond to administration of oxygen
Non cardiogenic
-due to intrapulmonary shunting
-persist despite oxygen supplimentation
Approach a Patient with
Pulm.Edema
History Taking
Exertional Dyspnea
Orthopnea
Aspiration of food or foreign body
Direct Chest injuries
Walking High altitude
Chest Pain(right or left)
Leg pain or swelling(Pulmonary Embolism)
A cough that produces frothy sputum that may be tinged with
blood(cardiogenic)
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
Past Medical History
COPD,
heart failure,
HIV risk factors
(pulmonary Kaposi’s sarcoma).
Prior chest X-rays,
CT scans,
tuberculin testing (PPD).
Medications
Anticoagulants
Aspirin
NSAIDs
Narcotic
Heroin
Morphine
Methadone and
Dextropropoxyphene
INVESTIGATIONS
CXR-PA view:
unilateral or bilateral involvement,cardiogenic
pattern or non cardiognic pattern(air bronchogram
signs, fluffy opacities, asymmetrical inhomogenous
involvement),lobar involvement in post infectious PE.
ABG analysis:
hypoxia and hypocapnia initially with respi. alkalois
hypercapnea in later stage with respi and
metabolic acidosis
Hemodynamic measurement with Swan-Ganz
catheter
Blood work up and septic screen
Management stretagy
NIV support:CPAP
Reasonable initial venti settings are EPAP 7 cmH2O
and IPAP of around 15 cm H2O with adjustment
according to patient tolerance and maintaining
SaO2>90%
Decreases work of breathing,FRC is
increased,collapse of alveoli due to edema fluid is
prevented and helps in opening up of already
collapsed alveoli
Good response is generally observed in 30 minutes,if
not so or worsening is seen, consider elective
intubation f/b venti support
Management stretagy…