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Updated: Apr 4 2018

Pulmonary Edema

  • Introduction
    • Fluid accumulation in air spaces and parenchyma of the lungs
      • leads to impaired gas exchange and may cause respiratory failure
    • Pathophysiology
      • edema arises due to an imbalance in hydrostatic and/or oncotic pressure
        • increased hydrostatic pressure in the pulmonary capillaries (Pc)
          • cardiogenic causes (see below)
        • decreased oncotic pressure in the pulmonary capillaries (πc)
          • kidney or liver dysfunction (e.g. nephrotic syndrome, cirrhosis)
        • movement of fluid is driven by Starling forces
    • Causes
      • changes in pressure are of cardiogenic or non-cardiogenic origin
      • cardiogenic causes include
        • heart failure
          • left heart failure
          • volume overload
          • mitral stenosis
        • in all cases above, an increase in left ventricular end diastolic volume increases hydrostatic pressure in LV, LA, pulmonary vein, and pulmonary capillaries
          • the increase in hydrostatic pressure overwhelms the oncotic pressure in the pulmonary capillaries
          • a transudate leaks into the interstitial space and ultimately into the alveoli
      • non-cardiogenic causes include
        • infection
          • sepsis
          • pneumonia
        • aspiration
          • drowning
          • gastric aspiration
        • drugs
          • heroin
        • high altitude
        • ARDS
          • alveolar-capillary damage
  • Presentation
    • Symptoms
      • dyspnea
        • including orthopnea and paroxysymal nocturnal dyspnea (PND)
    • Physical exam
      • bibasilar inspiratory crackles
        • due to air expanding fluid-filled alveoli
      • rusty-colored sputum
        • due to rupture of pulmonary capillaries from elevated hydrostatic pressure
      • wheezing
        • due to peribronchiolar edema
        • "cardiac asthma"
  • Evaluation
    • CXR
      • congestion in upper lobes
      • perihilar congestion
        • "bat wing configuration"
      • alveolar infiltrates
      • Kerley's lines
        • due to septal edema
    • Biopsy
      • hemosiderin-laden alveolar macrophages ("heart failure cells")
        • macrophages phagocytose blood following rupture of capillaries
  • Treatment
    • Treat underlying condition
      • nitrates and diuretics used for cardiogenic causes
    • Respiratory support
      • Non-invasive positive pressure ventilation
      • supplemental oxygen
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