Pulmonary edema
Revision as of 16:01, 8 January 2015 by Neil.m.young (talk | contribs)
Background
- Cardiogenic vs Non-Cardiogenic (ARDS/Altitude/Neurogenic)
- Mechanism of Cardiogenic
- Failing heart > pulm edema > stress response > incr afterload
- Incr afterload > incr pulm edema
- Failing heart > pulm edema > stress response > incr afterload
- Pts often intravascularly depleted; avoid diuretics!
Diagnosis
- Crackles
- Respiratory distress
Specific types
- Negative pressure pulmonary edema
- Forced inspiration against obstructed airway causes large negative intrathoracic pressure, leading to pulmonary edema[1]
- Mostly due to postoperative laryngospasm, sudden drops in PEEP (high PEEP to manual BVM), trauma such as hanging, strangulation, foreign bodies, etc.
- Diagnosis
- Hypoxemia (may be sudden and large - beware "fake" or "not real" SpO2), stridor, retractions, accessory muscle use, crackles/wheezes
- CXR shows diffuse interstitial and alveolar infiltrates
- CT shows preferential central/nondependent distribution of edema (as opposed to other forms of pulmonary edema)
- Treatment
- Relieve airway obstruction
- Vent with generous PEEP and diuretics
Treatment
- CPAP/BiPAP with PEEP 6-8; titrate up to PEEP of 10-12
- Nitroglycerin
- Dosing Options
- Sublingual 0.4 mg q5min
- Nitropaste (better bioavailability than oral Nitroglycerin)
- Intravenous: 0.1mcg/kg/min - 5mcg/kg/min
- Dosing Options
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
Source
Tintinalli
EMCrit Podcast 1
- ↑ Bhaskar B, Fraser JF. Negative pressure pulmonary edema revisited: Pathophysiology and review of management. Saudi J Anaesth. 2011 Jul-Sep; 5(3): 308–313.