Pulmonary Edema

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Life threatening condition that occurs due to abnormal fluid build-up in the lungs leading to impaired  gaseous exchange, acute respiratory distress and may cause respiratory failure. Can be classified  as cardiogenic pulmonary edema; due to increased hydrostatic pulmonary pressure (HF) and Non  cardiogenic  pulmonary  edema;  due  to  increased  permeability  (acute  lung  injury  and  allergic  alveolitis). 

Note 

Cardiogenic  and  non-cardiogenic  pulmonary  edema  have  no  clear  cut  differences  in  clinical  presentation,  however  identifying  the  specific  underlying  cause  of  pulmonary  edema  is  significant for therapeutic and prognostic purposes. 

Clinical presentation 

Shortness of breath, use of accessory muscles, diaphoresis, tachypnoea and crepitations 

Investigations 

Chest  X-ray,  Blood  gases,  Serum  Creatinine  and  Urea,  POC  ECG,  POC  troponin,  Serum  electrolytes and/orBedside Ultrasound 

Non Pharmacological management 

  • Perform both primary and secondary assessment and provide necessary interventions
  • Give high flow oxygen therapy
  • Put patient on cardiac monitor (if available) and obtain vital signs
  • Position patient at 45° angle or sitting upright position
  • Perform ECG (rule out ischemia, dysrhythmia)
  • Perform bedside ECHO (to rule out cardiac causes- contractility, pericardial effusion)
  • Perform chest ultrasound (comet tails and B lines)

Pharmacological management 

Control hypertension (for SBP>90mmHg) 

S: nitroglycerin  (IV):  Adult  loading  100mcg/min  titrate  rapidly  to  400mcg/min  over  2  minutes 

CAUTION! Beware of preload sensitive condition example inferior or right ventricular myocardial infarction,  phosphodiesterase inhibitors use 

Reduce intravascular volume if fluid overloaded 

B: furosemide (IV/IM):  0.5-1mg/kg over 20minutes (maximum 120mg) or infusion IV 5-10mg/kg 

(maximum 120mg)  

CAUTION! Beware of renal insufficiency and volume depleted patients, check size of IVC 

Ventilation 

Oxygen  therapy  (target  saturation>95%);  CPAP  or  BiPAP  (for  persistent  respiratory  distress,  hypoxia  or  acidosis  despite  high  flow  oxygen  therapy);  Intubation  and  mechanical  ventilation  (for  respiratory failure despite CPAP/BiPAP) 

Disposition 

Goal  of  treatment  -  Relieve  hypoxemia  (improve  oxygenation);  Reduction  of  pulmonary  capillary  pressure and improve perfusion. Admit all patients with pulmonary edema to HDU/ICU or transfer the  patient to a health facility with ICU/HDU capacity