Pulmonary edema

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Pulmonary edema
Classification and external resources

Acute pulmonary edema

ICD-10 J81.
ICD-9 514 518.4
DiseasesDB 11017
MedlinePlus 000140
eMedicine med/1955 radio/581
MeSH D011654

Pulmonary edema (American English), or oedema (British English, Greek οίδημα), is

fluid accumulation in the lungs.[1] It leads to impaired gas exchange and may cause
respiratory failure. It is due to either failure of the heart to remove fluid from the lung
circulation ("cardiogenic pulmonary edema") or a direct injury to the lung parenchyma
("noncardiogenic pulmonary edema").[2] Treatment depends on the cause, but focuses on
maximizing respiratory function and removing the cause.

Contents
[hide]

• 1 Signs and symptoms

• 2 Diagnosis
• 3 Causes
o 3.1 Cardiogenic
o 3.2 Non-cardiogenic
  3.2.1 Alveolar
 3.2.2 Other/unknown
• 4 Therapy
• 5 References
• 6 See also

• 7 External links

[edit] Signs and symptoms

Symptoms of pulmonary edema include difficulty breathing, coughing up blood,
excessive sweating, anxiety, and pale skin. A classic sign of pulmonary edema is the
production of pink frothy sputum. If left untreated, it can lead to coma and even death, in
general, due to its main complication of hypoxia. If pulmonary edema has been
developing gradually, symptoms of fluid overload may be elicited. These include
nocturia (frequent urination at night), ankle edema (swelling of the legs, in general, of the
"pitting" variety, wherein the skin is slow to return to normal when pressed upon),
orthopnea (inability to lie down flat due to breathlessness), and paroxysmal nocturnal
dyspnea (episodes of severe sudden breathlessness at night).

[edit] Diagnosis
In general, pulmonary edema is suspected due to findings in the medical history, such as
previous cardiovascular disease, and physical examination: End-inspiratory crackles
(sounds heard at the end of a deep breath) on auscultation (listening to the breathing
through a stethoscope) are characteristic for pulmonary edema. The presence of a third
heart sound (S3) is predictive of cardiogenic pulmonary edema.[2]

In general, blood tests are performed for electrolytes (sodium, potassium) and markers of
renal function (creatinine, urea). Liver enzymes, inflammatory markers (usually C-
reactive protein) and a complete blood count as well as coagulation studies (PT, aPTT)
are typically requested. B-type natriuretic peptide (BNP) is available in many hospitals,
sometimes even as a point-of-care test. Low levels of BNP (<100 pg/ml) make a cardiac
cause very unlikely.[2]

The diagnosis is confirmed on X-ray of the lungs, which shows increased fluid in the
alveolar walls. Kerley B lines, increased vascular filling, pleural effusions, upper lobe
diversion (increased blood flow to the higher parts of the lung) may be indicative of
cardiogenic pulmonary edema, whereas patchy alveolar infiltrates with air bronchograms
are more indicative of noncardiogenic edema[2]

Low oxygen saturation and disturbed arterial blood gas readings may strengthen the
diagnosis and provide grounds for various forms of treatment. If urgent echocardiography
is available, this may strengthen the diagnosis, as well as identify valvular heart disease.
In rare occasions, insertion of a Swan-Ganz catheter may be required to distinguish
between the two main forms of pulmonary edema.[2]

[edit] Causes
Pulmonary edema is either due to direct damage to the tissue or a result of inadequate
functioning of the heart or circulatory system.

When directly or indirectly caused by increased pulmonary blood pressure, pulmonary

edema may appear when this pressure increases from the normal 15 mmHg[3] to above 25
mmHg.[4]

[edit] Cardiogenic

• Congestive heart failure

• Severe heart attack with left ventricular failure
• Severe arrhythmias (tachycardia/fast heartbeat or bradycardia/slow heartbeat)
• Hypertensive crisis
• Pericardial effusion with tamponade
• Fluid overload, e.g., from kidney failure or intravenous therapy

[edit] Non-cardiogenic

May occur after upper airway obstruction, intravenous fluid overload, neurogenic causes
(seizures, head trauma, strangulation, electrocution). Can also be seen with ARDS (acute
respiratory distress syndrome):

[edit] Alveolar

• Inhalation of toxic gases

• Pulmonary contusion, i.e., high-energy trauma
• Aspiration, e.g., gastric fluid or in case of drowning
• Reexpansion, i.e. post pneumonectomy or large volume thoracentesis
• Reperfusion injury, i.e. postpulmonary thromboendartectomy or lung
transplantation
• Immersion pulmonary edema[5][6]
• Multiple blood transfusions
• Severe infection

[edit] Other/unknown

• Multitrauma, e.g., severe car accident

• Neurogenic, e.g., subarachnoid hemorrhage
• Certain types of medication, illicit drug use
• Upper airway obstruction, i.e. negative pressure pulmonary edema[7][8]
• Arteriovenous malformation
 • Hantavirus pulmonary syndrome
• Ascent to high altitude occasionally causes high altitude pulmonary edema
(HAPE)[9][10]

[edit] Therapy
Focus is initially on maintaining adequate oxygenation. This may happen with high-flow
oxygen, noninvasive ventilation (either continuous positive airway pressure (CPAP) or
variable positive airway pressure (VPAP)[11][12]) or mechanical ventilation in extreme
cases.

When circulatory causes have led to pulmonary edema, treatment with intravenous
nitrates (glyceryl trinitrate), and loop diuretics, such as furosemide or bumetanide, is the
mainstay of therapy. These improve both preload and afterload, and aid in improving
cardiac function.