Pulmonary Edema Disease

DESCRIPTION

Pulmonary interstitial and/or alveolar fluid accumulation that results when the forces moving fluid out of the pulmonary capillary exceed the forces restraining that fluid

System(s) affected: Cardiovascular, Pulmonary
Genetics: Multifactorial
Incidence/Prevalence in USA:
Approximately 150,000 persons per year in U.S. affected with non-cardiogenic pulmonary edema
Predominant age: Middle age and elderly
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Respiratory
- Shortness of breath
- Dyspnea with exertion
- Orthopnea, paroxysmal nocturnal dyspnea
- Cough, often accompanied by pink or blood-tinged and frothy sputum
- Wheezing, rhonchi, gurgles
- Moist, crepitant rales noted initially at bases and progressing to apices
- Breathlessness, air hunger
- Noisy respirations
- Tachypnea
- Dilated alae nasi
- Inspiratory retraction of the intercostal spaces and/or supraventricular fossae
- Cheyne-Stokes respirations
Cardiovascular
- Tachycardia
- Elevated jugular venous pulse
- Increased P2
- S3
- S4
- Nocturnal angina
- Pulsus alternans or presence of valvular heart disease
General
- Weakness, fatigue
- Other symptoms depending on etiology
- Anxiety
- Diaphoretic, cold, ashen, or cyanotic skin
- Lower extremity edema

CAUSES

Cardiogenic
- Left heart failure
- Ischemic heart disease
- Acute myocardial infarction
- Aortic and mitral valvular disease
- Hypertensive heart disease
- Cardiomyopathy
- Volume overload
- Arrhythmias
- Endocarditis
- Myocarditis
- Congenital heart disease
- Acute rheumatic fever and rheumatic heart disease
- Septal defects
- Cardiac tamponade
- High cardiac output states (e.g., thyrotoxicosis, beriberi)
Non-cardiogenic
- Shock
- Multiple trauma
- Infection/sepsis (especially pneumonia)
- Liquid aspiration (e.g., drowning, gastric contents)
- Inhaled toxic gases
- Pulmonary lymphatic obstruction
- Drug overdose (especially narcotics)
- High-altitude illness
- Pancreatitis
- Embolism (thrombus, fat, air, amniotic fluid)
- Neurogenic
- Hematologic and immunologic disorders
- Disorders associated with high negative pleural pressure
- Radiation pneumonitis
- Disseminated intravascular coagulation
- Eclampsia
- Decreased plasma oncotic pressure (e.g., hypoalbuminemia)
- After cardioversion, anesthesia, or cardiopulmonary bypass
- Oxygen toxicity
- ARDS
- Renal failure

RISK FACTORS

Dependent on etiology

LABORATORY

None specific for pulmonary edema; laboratory abnormalities (e.g., creatine kinase [CK], amylase, etc.) may point to underlying etiology
Hypoxemia
Hypocarbia
Respiratory alkalosis
Increased A-a gradient
Leukocytosis

Drugs that may alter lab results: Administered oxygen may complicate arterial blood gas interpretation
Disorders that may alter lab results: Underlying pulmonary disease from an unrelated etiology may complicate arterial blood gas interpretation

PATHOLOGICAL FINDINGS

Cardiogenic
- Heavy, wet, subcrepitant lungs
- Intra-alveolar granular pink precipitate
- Alveolar microhemorrhages and hemosiderin-laden macrophages
- "Brown induration," chronic passive congestion
- Hypostatic bronchopneumonia
Non-cardiogenic
- Heavy, firm, red, and boggy lungs
- Interstitial and intra-alveolar edema, inflammation, fibrin deposition, hemorrhage, and patchy atelectasis
- Hyaline membrane formation
- Interstitial and intra-alveolar fibrosis

SPECIAL TESTS

Arterial blood gas
Electrocardiogram
Pulmonary function tests
Mixed venous oxygen saturation

IMAGING

Two-dimensional echocardiography with Doppler may be useful in some cases of cardiogenic pulmonary edema (e.g., valvular heart disease, systolic vs. diastolic dysfunction)
Chest x-ray (may be difficult or impossible to differentiate cardiogenic from non-cardiogenic pulmonary edema)
- Cardiogenic chest x-ray; Interstitial edema, cardiomegaly, pulmonary venous redistribution, Kerley's B lines, alveolar edema (initially perihilar), pleural effusions (more common)
- Non-cardiogenic chest x-ray; alveolar edema, cardiomegaly absent, pulmonary venous redistribution absent, pleural effusions less common

DIAGNOSTIC PROCEDURES

Swan-Ganz catheter may help differentiate cardiogenic from non-cardiogenic pulmonary edema
Cardiac catheterization - occasionally beneficial

APPROPRIATE HEALTH CARE

Generally inpatient or intensive care; outpatient for mildest forms

GENERAL MEASURES

Treat underlying condition
Patient sitting, with legs dangling
Oxygen
Rotating tourniquets or phlebotomy selectively
Mechanical ventilation, often requiring positive end-expiratory pressure support
Rapid reduction in altitude in cases of high altitude pulmonary edema

SURGICAL MEASURES

N/A

ACTIVITY

Bedrest in most cases

DIET

Low sodium diet

PATIENT EDUCATION

Low sodium, fluid restriction
Symptoms and signs of pulmonary edema
Importance of medical compliance

PREVENTION/AVOIDANCE

Compliance with medications and diet

POSSIBLE COMPLICATIONS

Death
Reversible or irreversible organ ischemia
Pulmonary fibrosis, particularly with non-cardiogenic pulmonary edema

EXPECTED COURSE AND PROGNOSIS

Dependent on underlying etiology
Mortality approximately 50-60% for non-cardiogenic pulmonary edema and up to 80% for cardiogenic shock

ASSOCIATED CONDITIONS

(see Causes)

AGE-RELATED FACTORS

Pediatric: Usually secondary to lung immaturity, congenital heart disease, or associated with trauma
Geriatric: Higher mortality
Others: N/A

PREGNANCY

Pulmonary edema may occur as a complication of tocolytic therapy with magnesium sulfate, terbutaline or ritodrine

OTHER NOTES

N/A

ABBREVIATIONS

ARDS = adult respiratory distress syndrome

Clinical Investigations

ROLE OF HOMOEOPATHY

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