Updated: 4/4/2018

Pulmonary Edema

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Introduction
  • pulmonary edemaFluid 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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Questions (2)
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(M1.PL.15.102) A 65-year-old male with a past medical history of left ventricular hypertrophy presents to the emergency room because of a history of progressive shortness of breath and a cough productive of frothy pink sputum. Physical examination reveals crackles at the lung bases bilaterally. The patient denies fever, chills, or any recent infection. A radiograph of the chest shows septal lines and areas of opacification in both lung fields (see image).
Which of the following most likely accounts for this patient’s dyspnea?

QID: 100905
FIGURES:
1

Obstruction of blood flow through pulmonary arteries

2%

(1/62)

2

Destruction of interalveolar septa

11%

(7/62)

3

Excess mucous production in bronchiolar epithelium

6%

(4/62)

4

A collection of air in the pleural space

0%

(0/62)

5

Alveolar and interstitial fluid accumulation

81%

(50/62)

M 2 D

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