Pulmonary edema

Background

Causes

• Cardiogenic
• Non-cardiogenic
  • Hypertensive crisis.
• Negative pressure pulmonary edema
  • Upper airway obstruction
  • Reexpansion edema
• Neurogenic causes
  • Seizures
  • Blunt head trauma
  • Strangulation
  • Electrocution
• Other
  • ARDS
  • Inhalation injury
  • Pulmonary contusion
  • Aspiration
• Immersion pulmonary edema
• Iatrogenic fluid overload
  • Multiple blood transfusions
  • IV fluid
• Hantavirus pulmonary syndrome
• High altitude pulmonary edema

Diagnosis

• Crackles
• Respiratory distress

Differential Diagnosis

Acute dyspnea

Emergent

• Pulmonary
  • Airway obstruction
  • Anaphylaxis
  • Angioedema
  • Aspiration
  • Asthma
  • Cor pulmonale
  • Inhalation exposure
  • Noncardiogenic pulmonary edema
  • Pneumonia
  • Pneumocystis Pneumonia (PCP)
  • Pulmonary embolism
  • Pulmonary hypertension
  • Tension pneumothorax
  • Idiopathic pulmonary fibrosis acute exacerbation
  • Cystic fibrosis exacerbation
• Cardiac
  • Cardiac tamponade
  • Cardiogenic pulmonary edema (CHF)
  • Myocardial Infarction
  • Pericarditis
  • Myocarditis
• Other Associated with Normal/↑ Respiratory Effort
  • Abdominal distension
  • Anemia
  • CO Poisoning
  • Salicylate toxicity
  • Diabetic ketoacidosis (DKA)
  • Diaphragm injury
  • Electrolyte abnormalities
  • Epiglottitis
  • Flail chest
  • Hypotension
  • Metabolic acidosis
  • Pneumonia
  • Pneumothorax/hemothorax
  • Renal Failure
  • Sepsis
  • Toxic ingestion
• Other Associated with ↓ Respiratory Effort
  • Guillain-Barre syndrome
  • Multiple sclerosis
  • Myasthenia Gravis
  • Lambert-Eaton Syndrome
  • Organophosphate toxicity
  • Stroke (Main)
  • Tick paralysis

Non-Emergent

• ALS
• Ascites
• Uncorrected ASD
• Congenital heart disease
• COPD exacerbation
• Fever
• Hyperventilation
• Interstitial lung disease
• Neoplasm
• Obesity
• Panic attack
• Pleural effusion
• Polymyositis
• Porphyria
• Pregnancy
• Rib fracture
• Spontaneous pneumothorax
• Thyroid Disease
• URI

Treatment

1. CPAP/BiPAP with PEEP 6-8; titrate up to PEEP of 10-12
2. Nitroglycerin
   1. Dosing Options
      1. Sublingual 0.4 mg q5min
      2. Nitropaste (better bioavailability than oral Nitroglycerin)
      3. Intravenous: 0.1mcg/kg/min - 5mcg/kg/min

Generally start IV Nitroglycerin 50mcg/min and titrate rapidly (150mcg/min or higher)to symptom relief

• If NTG fails to reduce BP consider nitroprusside (reduces both preload and afterload) or ACE-inhibitiors (preload reducer)
• After pt improves titrate down NTG as enaliprilat (0.625 - 1.25mg IV) or captopril are started
• Morphine is no longer recommended do to increased morbidity

See Also

• Congestive Heart Failure (CHF)
• Acute Respiratory Distress Syndrome