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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 (1)

(M1.PL.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? Review Topic

QID: 100905
FIGURES:
1

Obstruction of blood flow through pulmonary arteries

0%

(0/8)

2

Destruction of interalveolar septa

25%

(2/8)

3

Excess mucous production in bronchiolar epithelium

25%

(2/8)

4

A collection of air in the pleural space

0%

(0/8)

5

Alveolar and interstitial fluid accumulation

50%

(4/8)

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PREFERRED RESPONSE 5
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