Fluid accumulation in the tissue and air spaces of the lungs
Medical condition
Pulmonary edema
|
---|
Other names
| Pulmonary oedema
|
---|
|
Pulmonary edema with small
pleural effusions
on both sides
|
Specialty
| Cardiology
,
critical care medicine
pulmonology
|
---|
Symptoms
| Progressive dyspnea, cough, fever, cyanosis, tachycardia
|
---|
Complications
| ARDS, respiratory failure
|
---|
Causes
| Cardiogenic, Noncardiogenic (pneumonia, inhalation injury, sepsis, airway obstruction, high altitude)
|
---|
Diagnostic method
| Medical imaging, lab tests, ECG, echocardiography
|
---|
Treatment
| Supplemental oxygen, diuretics, treat underlying disease process
|
---|
Pulmonary edema
(
British English
: oedema), also known as
pulmonary congestion
, is excessive
fluid accumulation
in the
tissue
or
air spaces
(usually
alveoli
) of the
lungs
.
[1]
This leads to impaired
gas exchange
, most often leading to
dyspnea
which can progress to
hypoxemia
and
respiratory failure
. Pulmonary edema has multiple causes and is traditionally classified as
cardiogenic
(caused by the heart) or noncardiogenic (all other types not caused by the heart).
[2]
[3]
Various laboratory tests (
CBC
,
troponin
,
BNP
, etc.) and imaging studies (
chest x-ray
,
CT scan
,
ultrasound
) are often used to diagnose and classify the cause of pulmonary edema.
[4]
[5]
[6]
Treatment is focused on three aspects: improving respiratory function, treating the underlying cause, and preventing further damage and allow full recovery to the lung. Pulmonary edema can cause permanent organ damage, and when sudden (acute), can lead to
respiratory failure
or
cardiac arrest
due to
hypoxia
.
[7]
The term edema is from the
Greek
ο?δημα
(
oid?ma
, "swelling"), from ο?δ?ω (
oide?
, "(I) swell").
[8]
[9]
Pathophysiology
[
edit
]
The amount of fluid in the lungs is governed by multiple forces and is visualized using the
Starling equation
. There are two
hydrostatic pressures
and two
oncotic (protein) pressures
that determine the fluid movement within the lung air spaces (
alveoli
). Of the forces that explain fluid movement, only the
pulmonary wedge pressure
is obtainable via
pulmonary artery catheterization
.
[10]
Due to the complication rate associated with pulmonary artery catheterization, other imaging modalities and diagnostic methods have become more popular.
[11]
Imbalance in any of these forces can cause fluid movement (or lack of movement) causing a buildup of fluid where it should not normally be. Although rarely clinically measured, these forces allow physicians to classify and subsequently treat the underlying cause of pulmonary edema.
Classification
[
edit
]
Pulmonary edema has a multitude of causes, and is typically classified as cardiogenic or noncardiogenic. Cardiogenic pulmonary edema is caused by increased hydrostatic pressure causing increased fluid in the pulmonary interstitium and
alveoli
. Noncardiogenic causes are associated with the oncotic pressure as discussed above causing malfunctioning barriers in the lungs (increased
microvascular permeability
).
[12]
Cardiogenic
[
edit
]
Cardiogenic pulmonary edema is typically caused by either volume overload or impaired
left ventricular
function. As a result,
pulmonary pressures
rises from the normal average of 15 mmHg.
[13]
As the pulmonary pressure rises, these pressures overwhelm the barriers and fluid enters the alveoli when the pressure is above 25 mmHg.
[14]
Depending whether the cause is acute or chronic determines how fast pulmonary edema develops and the severity of symptoms.
[12]
Some of the common causes of cardiogenic pulmonary edema include:
- Acute exacerbation of
congestive heart failure
which is due to the heart's inability to pump the blood out of the pulmonary circulation at a sufficient rate resulting in elevation in
pulmonary wedge pressure
and edema.
- Pericardial tamponade
as well as treating pericardial tamponade via
pericardiocentesis
has shown to cause pulmonary edema as a result of increased left-sided heart strain.
[15]
- Heart Valve Dysfunction
such as mitral valve regurgitation can cause increased pressure and energy on the left side of the heart (increased pulmonary wedge pressure) causing pulmonary edema.
[16]
- Hypertensive crisis
can cause pulmonary edema as the elevation in blood pressure and increased
afterload
on the left ventricle hinders forward flow in blood vessels and causes the elevation in
wedge pressure
and subsequent pulmonary edema. In a recent systematic review, it was found that pulmonary edema was the second most common condition associated with hypertensive crisis after
ischemic stroke
.
[17]
Flash Pulmonary Edema
[
edit
]
A particularly severe type of cardiogenic pulmonary edema is flash pulmonary edema (FPE). Flash pulmonary edema is a clinical syndrome of acute heart failure that begins suddenly and accelerates rapidly. Frequently the most noticeable abnormality is edema of the lungs. Nevertheless it is a cardiovascular disease not a pulmonary disease. It is also known by other appellations including sympathetic crashing acute pulmonary edema (SCAPE).
[18]
It is often associated with severe hypertension
[19]
Typically, patients with the syndrome of flash pulmonary edema do not have chest pain are often not recognized as having a cardiovascular disease. Treatment of FPE should include reducing systemic vascular resistance with nitroglycerin, providing supplemental oxygenation, and decreasing pulmonary circulation pressures while FPE stays.
[20]
Recurrence of FPE is thought to be associated with
hypertension
[21]
and may signify
renal artery stenosis
.
[22]
Prevention of recurrence is based on managing or preventing hypertension,
coronary artery disease
,
renovascular hypertension
, and heart failure.
Noncardiogenic
[
edit
]
Noncardiogenic pulmonary edema is caused by increased
microvascular permeability
(increased
oncotic pressure
) leading to increased fluid transfer into the alveolar spaces. The pulmonary artery wedge pressure is typically normal as opposed to cardiogenic pulmonary edema where the elevated pressure is causing the fluid transfer. There are multiple causes of noncardiogenic edema with multiple subtypes within each cause.
Acute respiratory distress syndrome
(ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Although ARDS can present with pulmonary edema (fluid accumulation), it is a distinct clinical syndrome that is not synonymous with pulmonary edema.
Direct Lung Injury
[
edit
]
Acute lung injury
may cause pulmonary edema directly through injury to the vasculature and parenchyma of the lung, causes include:
- Inhalation of hot or toxic gases
[12]
(including
vaping-associated lung injury
)
- Pulmonary contusion
, i.e.,
high-energy trauma
(e.g. vehicle accidents)
- Aspiration
, e.g., gastric fluid
- Reexpansion, i.e. post large volume
thoracocentesis
, resolution of pneumothorax, post decortication, removal of endobronchial obstruction, effectively a form of negative pressure pulmonary oedema.
- Reperfusion injury, i.e., postpulmonary
thromboendartectomy
or
lung transplantation
- Swimming induced pulmonary edema
also known as immersion pulmonary edema
[23]
[24]
[25]
- Transfusion associated Acute Lung Injury
is a specific type of blood-product transfusion injury that occurs when the donors plasma contained antibodies against the recipient, such as anti-HLA or anti-neutrophil antibodies.
[26]
Indirect Lung Injury
[
edit
]
Special Causes
[
edit
]
Some causes of pulmonary edema are less well characterized and arguably represent specific instances of the broader classifications above.
Signs and symptoms
[
edit
]
The most common symptom of pulmonary edema is
dyspnea
and may include other symptoms relating to inadequate oxygen (
hypoxia
) such as fast breathing (
tachypnea
),
tachycardia
and
cyanosis
. Other common symptoms include
coughing up blood
(classically seen as pink or red, frothy sputum),
excessive sweating
,
anxiety
, and
pale skin
. Other signs include end-inspiratory
crackles
(crackling sounds heard at the end of a deep breath) on
auscultation
and the presence of a
third heart sound
.
[3]
Shortness of breath
can manifest as
orthopnea
(inability to breathe sufficiently when lying down flat due to breathlessness) and/or
paroxysmal nocturnal dyspnea
(episodes of severe sudden breathlessness at night). These are common presenting symptoms of chronic and cardiogenic pulmonary edema due to left ventricular failure.
The development of pulmonary edema may be associated with symptoms and signs of "fluid overload" in the lungs; this is a non-specific term to describe the manifestations of
right
ventricular failure on the rest of the body. These symptoms may include peripheral
edema
(swelling of the legs, in general, of the "pitting" variety, wherein the skin is slow to return to normal when pressed upon due to fluid), raised
jugular venous pressure
and
hepatomegaly
, where the liver is excessively enlarged and may be tender or even pulsatile.
Additional symptoms such as fever, low blood pressure, injuries or burns may be present and can help characterize the cause and subsequent treatment strategies.
Diagnosis
[
edit
]
There is no single test for confirming that breathlessness is caused by pulmonary edema ? there are many causes of
shortness of breath
; but there are methods to suggest a high probability of an edema.
Lab Tests
[
edit
]
Low
oxygen saturation
in blood and disturbed
arterial blood gas
readings support the proposed diagnosis by suggesting a
pulmonary shunt
. Blood tests are performed for
electrolytes
(sodium, potassium) and markers of
renal function
(creatinine, urea). Elevated creatine levels may suggest a cardiogenic cause of pulmonary edema.
[12]
Liver enzymes
, inflammatory markers (usually
C-reactive protein
) and a
complete blood count
as well as
coagulation
studies (PT, aPTT) are also typically requested as further diagnosis. Elevated white blood cell count (
WBC
) may suggest a non-cardiogenic cause such as sepsis or infection.
[12]
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) suggest a cardiac cause is unlikely, and suggest noncardiogenic pulmonary edema.
[3]
Imaging Tests
[
edit
]
Chest X-ray has been used for many years to diagnose pulmonary edema due to its wide availability and relatively cheap cost.
[4]
A
chest X-ray
will show fluid in the alveolar walls,
Kerley B lines
, increased vascular shadowing in a classical batwing peri-
hilum
pattern, upper lobe diversion (biased blood flow to the superior parts instead of inferior parts of the lung), and possibly
pleural effusions
. In contrast, patchy alveolar infiltrates are more typically associated with noncardiogenic edema.
[3]
Lung
ultrasounds
, employed by a healthcare provider at the point of care, is also a useful tool to diagnose pulmonary edema; not only is it accurate, but it may quantify the degree of lung water, track changes over time, and differentiate between cardiogenic and non-cardiogenic edema.
[36]
Lung ultrasound is recommended as the first-line method due to its wide availability, ability to be performed bedside, and wide diagnostic utility for other similar diseases.
[4]
Especially in the case of cardiogenic pulmonary edema, urgent
echocardiography
may strengthen the diagnosis by demonstrating impaired left ventricular function, high
central venous pressures
and high
pulmonary artery
pressures leading to pulmonary edema.
Prevention
[
edit
]
In those with underlying heart or lung disease, effective control of congestive and respiratory symptoms can help prevent pulmonary edema.
[37]
Dexamethasone
is in widespread use for the prevention of
high altitude pulmonary edema
.
Sildenafil
is used as a preventive treatment for altitude-induced pulmonary edema and pulmonary hypertension.
[38]
[39]
Sildenafil's mechanism of action is via phosphodiesterase inhibition which raises cGMP, resulting in pulmonary arterial vasodilation and inhibition of smooth muscle cell proliferation and indirectly fluid formation in the lungs.
[40]
While this effect has only recently been discovered, sildenafil is already becoming an accepted treatment for this condition, in particular in situations where the standard treatment of rapid descent (acclimatization) has been delayed for some reason.
[41]
Management
[
edit
]
The initial management of pulmonary edema, irrespective of the type or cause, is supporting vital functions while edema lasts.
Hypoxia
may require supplementary oxygen to balance blood oxygen levels, but if this is insufficient then again mechanical ventilation may be required to prevent complications caused by hypoxia.
[42]
Therefore, if the level of consciousness is decreased it may be required to proceed to
tracheal intubation
and
mechanical ventilation
to prevent airway compromise. Treatment of the underlying cause is the next priority; pulmonary edema secondary to infection, for instance, would require the administration of appropriate
antibiotics
or
antivirals
.
[2]
[3]
Cardiogenic pulmonary edema
[
edit
]
Acute cardiogenic pulmonary edema often responds rapidly to medical treatment.
[43]
Positioning upright may relieve symptoms. A
loop diuretic
such as
furosemide
is administered, often together with
morphine
to reduce respiratory distress.
[43]
Both diuretic and morphine may have
vasodilator
effects, but specific vasodilators may be used (particularly intravenous
glyceryl trinitrate
or
ISDN
) provided the blood pressure is adequate.
[43]
Continuous positive airway pressure
and
bilevel positive airway pressure
(CPAP/BiPAP) has been demonstrated to reduce mortality and the need of mechanical ventilation in people with severe cardiogenic pulmonary edema.
[44]
It is possible for cardiogenic pulmonary edema to occur together with
cardiogenic shock
, in which the cardiac output is insufficient to sustain an adequate blood pressure to the lungs. This can be treated with
inotropic agents
or by
intra-aortic balloon pump
, but this is regarded as temporary treatment while the underlying cause is addressed and the lungs recover.
[43]
Prognosis
[
edit
]
As pulmonary edema has a wide variety of causes and presentations, the outcome or prognosis is often disease-dependent and more accurately described in relation to the associated syndrome. It is a major health problem, with one large review stating an incidence of 7.6% with an associated in hospital mortality rate of 11.9%.
[2]
Generally, pulmonary edema is associated with a poor prognosis with a 50% survival rate at one year, and 85% mortality at six years.
[45]
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Classification
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External resources
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