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
  • 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

  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

Source

Tintinalli

EMCrit Podcast 1

  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.