Pulmonary edema: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
{{Pulmonary edema clinical features}} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{SOB DDX}} | {{SOB DDX}} | ||
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[[File:PedalEdema.jpg|thumb|Pitting pedal edema]] | [[File:PedalEdema.jpg|thumb|Pitting pedal edema]] | ||
[[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]] | [[File:PulmEdema.png|thumb|Pulmonary edema with small pleural effusions on both sides.]] | ||
*CBC ( | [[File:Pulmonary Edema Bowra.gif|thumbnail|POCUS shows B lines<ref>http://www.thepocusatlas.com/pulmonary/</ref>]] | ||
*CBC (rule out anemia) | |||
*Chem | *Chem | ||
*ECG | *Albumin level | ||
*CXR | *[[ECG]] | ||
*[[CXR]] | |||
**Cephalization | **Cephalization | ||
**Interstitial edema | **Interstitial edema | ||
Line 22: | Line 22: | ||
**Alveolar edema | **Alveolar edema | ||
**Cardiomegaly | **Cardiomegaly | ||
*Troponin | *[[Troponin]] +/- BNP | ||
*[[Ultrasound]] | *[[Ultrasound]] | ||
**Bedside to assess [[ | **Bedside to assess [[Cardiac ultrasound|global function]], [[Ultrasound: lungs|B lines]], [[IVC ultrasound|assessment of IVC]] | ||
**Formal TTE/TEE | **Formal TTE/TEE | ||
{{BNP value}} | {{BNP value}} | ||
{{Lung ultrasound pulmonary edema}} | |||
==Management== | ==Management== | ||
*CPAP/BiPAP with PEEP 6-8; titrate up to PEEP of 10-12 | *CPAP/[[BiPAP]] with PEEP 6-8; titrate up to PEEP of 10-12 | ||
*Nitroglycerin | *[[Nitroglycerin]] | ||
**Dosing Options | **Dosing Options | ||
***Sublingual 0.4mg q5min | ***Sublingual 0.4mg q5min | ||
***Nitropaste (better bioavailability than oral Nitroglycerin) | ***Nitropaste (better bioavailability than oral Nitroglycerin) | ||
***Intravenous: 0.1mcg/kg/min - 5mcg/kg/min | ***Intravenous: 0.1mcg/kg/min - 5mcg/kg/min | ||
****Generally start IV | ****Generally start IV nitroglycerin 50mcg/min and titrate rapidly (150mcg/min or higher) to symptom relief as long as patient's blood pressure tolerates | ||
*If [[nitroglycerin]] fails to reduce work of breathing, consider nitroprusside (reduces both preload and afterload) or ACE-inhibitiors (preload reducer) | |||
*If | *After patient improves, titrate down [[nitroglycerin]] as [[enalaprilat]] (0.625 - 1.25mg IV) or [[captopril]] are started | ||
*After patient improves titrate down | *Morphine is no longer recommended due to increased morbidity<ref>Peacock WF, Hollander JE, Diercks DB, Lopatin M, Fonarow G, Emerman CL. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008 Apr;25(4):205-9.</ref><ref>Ellingsrud C, Agewall S. Morphine in the treatment of acute pulmonary oedema--Why? Int J Cardiol. 2016 Jan 1;202:870-3.</ref> | ||
*Morphine is no longer recommended | |||
==Disposition== | ==Disposition== | ||
*Depends on underlying cause, hemodynamic stability, and response to treatment | |||
==See Also== | ==See Also== | ||
*[[Congestive | *[[Congestive heart failure]] | ||
*[[Acute Respiratory Distress Syndrome]] | *[[Acute Respiratory Distress Syndrome]] | ||
*[[ | *[[Flash pulmonary edema]] | ||
==References== | ==References== |
Latest revision as of 00:15, 8 September 2021
Background
Pulmonary Edema Types
Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema[1]
- Cardiogenic pulmonary edema
- Noncardiogenic pulmonary edema
- Negative pressure pulmonary edema
- Upper airway obstruction
- Reexpansion pulmonary edema
- Strangulation
- Neurogenic causes
- Iatrogenic fluid overload
- Multiple blood transfusions
- IV fluid
- Inhalation injury
- Pulmonary contusion
- Aspiration pneumonia and pneumonitis
- Other
- High altitude pulmonary edema
- Hypertensive emergency
- ARDS
- Flash pulmonary edema
- Immersion pulmonary edema
- Hantavirus pulmonary syndrome
- Missed dialysis in kidney failure
- Naloxone reversal
- Negative pressure pulmonary edema
Clinical Features
- Crackles
- Respiratory distress
- Increased jugular venous distension
- Signs of poor organ perfusion
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
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
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
Evaluation
- CBC (rule out anemia)
- Chem
- Albumin level
- ECG
- CXR
- Cephalization
- Interstitial edema
- Pulmonary venous congestion
- Pleural effusion
- Alveolar edema
- Cardiomegaly
- Troponin +/- BNP
- Ultrasound
- Bedside to assess global function, B lines, assessment of IVC
- Formal TTE/TEE
Brain natriuretic peptide (BNP)[3]
- Measurement
- <100 pg/mL: Negative for acute CHF (Sn 90%, NPV 89%)
- 100-500 pg/mL: Indeterminate (Consider differential diagnosis and pre-test probability)
- >500 pg/mL: Positive for acute CHF (Sp 87%, PPV 90%)
- Combination of BNP with clinician judgment 94% sensitive 70% specific (compared to 49% sn and 96% spec clinical judgement alone) [4]
NT-proBNP[5][6][7]
- <300 pg/mL → CHF unlikely
- CHF likely in:
- >450 pg/mL in age < 50 years old
- >900 pg/mL in 50-75 years old
- >1800 pg/mL in > 75 years old
Lung ultrasound of pulmonary edema
- A lines and B lines
- A lines:
- Appear as horizontal lines
- Indicate dry interlobular septa.
- Predominance of A lines has 90% sensitivity, 67% specificity for pulmonary artery wedge pressure <= 13mm Hg
- A line predominance suggests that intravenous fluids may be safely given without concern for pulmonary edema
- B lines ("comets"):
- White lines from the pleura to the bottom of the screen
- Highly sensitive for pulmonary edema, but can be present at low wedge pressures
- A lines:
Management
- CPAP/BiPAP with PEEP 6-8; titrate up to PEEP of 10-12
- Nitroglycerin
- Dosing Options
- Sublingual 0.4mg q5min
- Nitropaste (better bioavailability than oral Nitroglycerin)
- Intravenous: 0.1mcg/kg/min - 5mcg/kg/min
- Generally start IV nitroglycerin 50mcg/min and titrate rapidly (150mcg/min or higher) to symptom relief as long as patient's blood pressure tolerates
- Dosing Options
- If nitroglycerin fails to reduce work of breathing, consider nitroprusside (reduces both preload and afterload) or ACE-inhibitiors (preload reducer)
- After patient improves, titrate down nitroglycerin as enalaprilat (0.625 - 1.25mg IV) or captopril are started
- Morphine is no longer recommended due to increased morbidity[8][9]
Disposition
- Depends on underlying cause, hemodynamic stability, and response to treatment
See Also
References
- ↑ Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.
- ↑ http://www.thepocusatlas.com/pulmonary/
- ↑ Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347(3):161-167. doi:10.1056/NEJMoa020233.
- ↑ McCullough et al. B-Type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from breathing not properly (BNP) multinational study. Circulation. 2002:DOI: 10.1161/01.CIR.0000025242.79963.4
- ↑ Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J. 2006 Feb. 27(3):330-7.
- ↑ Kragelund C, Gronning B, Kober L, Hildebrandt P, Steffensen R. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med. 2005 Feb 17. 352(7):666-75.
- ↑ Moe GW, Howlett J, Januzzi JL, Zowall H,. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study. Circulation. 2007 Jun 19. 115(24):3103-10.
- ↑ Peacock WF, Hollander JE, Diercks DB, Lopatin M, Fonarow G, Emerman CL. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008 Apr;25(4):205-9.
- ↑ Ellingsrud C, Agewall S. Morphine in the treatment of acute pulmonary oedema--Why? Int J Cardiol. 2016 Jan 1;202:870-3.