Acute Lung

Oedema

by:
Muhammad Zhikron Octoprima Orsal
Nadhirah Sa’an
Nurul Khairantih
Roji Dhia Nurman
Siti Umi Kustiah

Preceptor : dr. M. Fadil, SpJP (K)

Introduction
 Background

Acute pulmonary edema is a pathological

condition, which is caused by the transfer of
intravascular fluid to the extravascular space,
interstitial tissue and pulmonary alveoli.
 Background

Pulmonary edema can be classified as -

cardiogenic pulmonary edema and non-
cardiogenic pulmonary edema.

Although the causes of cardiogenic and

non-cardiogenic pulmonary edema are
different, they both have similar clinical
appearances making it difficult to make a
diagnosis.
Some disposition factors are associated with the
development of pulmonary edema

Ischemic Condition Arrhythmia 31 % High systolic blood

51% pressure (> 180
mmHg). 29 %
Prevalencies

74,4 Millon
incidence rate (IR) in Indonesia

35,19 % 15,99 % 23,87%

1998 1999 2000 2002 2003

10,17%, 19,24%
Literature Review
Definition

Acute pulmonary edema is a pathological

state, caused by the transfer of intravascular
fluid to the extravascular space, interstitial
tissue and alveoli in an acute manner. Acute
pulmonary edema can occur due to heart
disease or diseases outside the heart
(cardiogenic and non cardiogenic pulmonary
edema).
Epidemiology

UK

74,4 Millon 6 Million 5,5 Million 2,1 Million

 Epidemiology in Indonesia
Pulmonary edema was first
announced in Indonesia in 1971.
Since it was first discovered, the Acute cardiogenic
amount displayed increased in pulmonary edema is
large numbers.
common, and has a
In Indonesia, incidents spread detrimental and lethal
since 1998 with an incidence rate
(IR) = 35.19 per 100,000 effect with a mortality
population. In 1999 IR decreased rate of 10-20%.
sharply by 10.17%, but in the
following years IR increased by
15, 99% (in 2000), 19.24% (in
2002), and 23.87% (in 2003).
 ETIOLOGY AND PATHOGENESIS OF PULMONARY EDEMA

Cardiogenic (overload volume)

occurs due to hydrostatic pressure in
the pulmonary capillaries which causes
an increase in transvascular fluid filtration.
part of the clinical spectrum of AHFS.

Nieminen MS, Bohm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, et al. Executive su
mmary of the guidelines on the diagnosis and treatment of acute heart failure. Eur Heart J. 20
05
Non cardiogenic
occurs due to transudation of fluid from
the pulmonary capillaries into the
interstitial space and lung alveoli
resulting from abnormalities besides
heart.

Givertz MM. Noncardiogenic Pulmonary Edema. Februari 2017

The causes of non cardiogenic
pulmonary edema are:
1. Impaired permeability of the alveoli
capillary membrane
due to in pulmonary capillary
permeability it is also often called ARDS.
 2. Increased pulmonary capillary pressure
A. Excessive infusion of intravenous fluids

Intrav vol expansion doesn’t need to be too large for

VC, because systemic vasocontr can cause a shift
in blood volume into the central circulation. This VCS
(fluid overload) often occurs in patients with extensive
trauma who receive large amounts of intravenous
crystalloid or blood, especially with impaired kidney
function.

Harun S dan Sally N. Edema Paru Akut. 2009. In: Sudoyo AW, Setiyohadi B, Alwi I, Sim
adibrata M, Setiati S, editor. Buku ajar ilmu penyakit dalam. 5th Ed.
B. Noncardiac causes
1. Pulmonary venous fibrosis
2. Congenital stenosis of the origin of
3. Pulmonary venoocclusive disease
3. Decreased oncotic pressure
Hypoalbuminemia from any cause
(renal , hepatic, nutritional, or protein-los
ing enteropathy).
 4. Lymphatic insufficiency
as a result of lung transplantation, lymph
angiectatic carcinomatosis, or fibrosis ly
mphangitis.

Nieminen MS, Bohm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, et al. E
xecutive summary of the guidelines on the diagnosis and treatment of acute heart
failure. Eur Heart J. 2005
 5. Mixed or unknown mechanisms
A. High-altitude pulmonary edema
altitude above 2700 meters, presumably the
mechanism is hypoxia because altitude causes
pulmo arteriole vasoconstr and excessive activity
stimulates increases of CO and pulmonary artery
pressure, resulting in PE.

Gomersall C. Noncardiogenic Pulmonary Oedema. Update: June 2009.

B. Neurogenic pulmonary edema

Spinal cord injury, seizure, ICH, Brain

trauma, SDH, SAH

Elevation of intracranial pressure

Gomersall C. Noncardiogenic Pulmonary Oedema. Update: June 2009.

PrasannaUB. Complications in Neuroanesthesia. Science direct.
2016
 PATHOPHYSIOLOGY

Lorraine et al. Acute Pulmonary Edema. N Engl J Med. 2005

 Pathophysiologic mechanisms:
 Imbalance of Starling forces
Ie, increased pulmonary capillary
pressure, decreased plasma oncotic
pressure, increased negative interstitial
pressure
Damage to the alveolar-capillary
barrier
Lymphatic obstruction
Idiopathic (unknown) mechanism

Harun S dan Sally N. Edema Paru Akut. 2009. In: Sudoyo AW, Setiyohadi B, Alwi I,
Simadibrata M, Setiati S, editor. Buku ajar ilmu penyakit dalam. 5th Ed.
• LAW STARLING
Q(iv-int)=Kf[(Piv-Pint) – df(Iiv-Iint)]
 Q = the rate of transudation of a
blood vessel into the interstitial space
 Piv = intravascular hydrostatic
pressure
 Pint = interstitial hydrostatic pressure
 Iiv = intravascular colloidal osmotic
pressure
 Iint = interstitial colloid osmotic
pressure
 Df = protein reflection coefficient
 Kf = hydraulic condensation

Harun S dan Sally N. Edema Paru Akut. 2009. In: Sudoyo AW, Setiyohadi B, Alwi I, Sim
adibrata M, Setiati S, editor. Buku ajar ilmu penyakit dalam. 5th Ed.
Lorraine et al. Acute Pulmonary Edema. N Engl J Med. 2005
Acute pulmonary non-cardiogenic edema after extubation with laryngospasm: a case report. Researchgate. 2018
Diagnosis

History

Physical Examination

Supporting Investigation
 The following two fundamentally different types of pulmonary ed
ema occur in humans:

Cardiogenic pulmonary
edema (also termed hydr
ostatic or hemodynamic
edema)
Noncardiogenic pulmo
nary edema (also known
as increased-permeability
pulmonary edema, acute
lung injury, or acute respi
ratory distress syndrome)
.

Although they have distinct causes, cardiogenic and noncardiogenic pulmonary edema may be
difficult to distinguish because of their similar clinical manifestations.
 Diagnosis

The presenting features of acute cardiogenic and noncardiogenic

pulmonary edema are similar.

Interstitial edema causes dyspnea and tachypnea.

Alveolar flooding leads to arterial hypoxemia and

may be associated with cough and expectoration of
frothy edema fluid.
TheHeart.orgMedscape. Acute Pulmonary Edema.The New
2017 England Journal of Medicine.
TheHeart.orgMedscape. Acute Pulmonary Edema.The New
2017 England Journal of Medicine.
TheHeart.orgMedscape. Acute Pulmonary Edema.The New
2017 England Journal of Medicine.
TheHeart.orgMedscape. Acute Pulmonary Edema.The New
2017 England Journal of Medicine.
TheHeart.orgMedscape. Acute Pulmonary Edema.The New
2017 England Journal of Medicine.
PHYSICAL FINDINGS THAT MAY BE ASS
OCIATED WITH PULMONARY EDEMA
Additional tests used in patients with suspected ALO include:

1. Laboratory tests
2. Chest Radiograph
3. Transthoracic Echocardiogram
4. Pulmonary Artery Catheterization
5. Electrocardiogram
 CHEST RADIOGRAPH

Source : Assaad S, Kratzert WB, Shelley B, Friedman MB, Jr AP. Assessment of Pulmonary
Edema : Principles and Practice. 2018;32:901–14.
 Laboratory tests

Liver function tests

BNP
Glucose
Cardiac troponins
Blood urea nitrogen (BUN)/urea Complete blood count
Creatinine Thyroid-stimulating
Electrolytes (sodium, potassium) hormone (TSH)
Acid-base balance
Algorithm for the Clinical Differentiation between Cardiogenic and Noncardioge
nic Pulmonary Edema
Treatment
Noncardiac Pulmonary Edema

Supportive
supportive management is useful for finding and tre
ating the cause. What must be done is:
- Supports cardiovascular
- Fluid therapy
- Kidney support
- Management of sepsis

Ventilation
*
 *

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
Recommendation pharmacotherapy for management of patients with AHF

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2016
 *
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2016
Inotropes and /or Vasopressors
Prognostic

• History of previous cardiovascular event

• Cardiomyopathy
• LVEF
• Systolic blood pressure
• Serum creatinine at presentation
• Treatment with diuretics

Parissis JT, Nikolaou M, Mebazaa A, Ikonomidis I, Delgado J, Boas FV, et al. acute
pulmonary oedema: clinical, characteristics,
prognostic factors, and in-hospital management. European Journal of Heart Failure.
2010;12:1193-1202
Closing
 Summary
The diagnosis of acute pulm
Acute pulmonary onary edema can be
edema can be divided identified through the history
into cardiogenic and of the patient's symptoms,
non cardiogenic. physical examination, and
investigation.

Treatment of acute
pulmonary edema is
aimed at the primary
disease.
Thank you