Introduction • The immediate area outside of the small blood vessels in the lungs is occupied by very tiny air sacs called the alveoli, where oxygen from the air is picked up by the blood passing by and carbon dioxide in the blood is passed into the alveoli to be exhaled out. • Alveoli normally have a thin wall that allows air exchange, and fluids are usually kept out of the alveoli unless these walls lose their integrity.
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• Oedema, in general means swelling. This typically occurs when fluid from inside blood vessels seeps outside the blood vessel into the surrounding tissues, causing swelling. • This can happen either because of too much pressure in the blood vessels or not enough proteins in the bloodstream to hold on to the fluid in the plasma. • Pulmonary oedema is the term used when oedema happens in the lungs.
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Definition • Acute pulmonary oedema is a pathophysiological state characterized by fluid-filled alveolar spaces and lung interstitium, with impaired alveolar gas exchange and reduced lung compliance.
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• APO occurs when – increased pulmonary capillary pressure – reduced plasma oncotic pressure – pulmonary capillary permeability changes – damage to the alveolar – idiopathic (unknown) mechanism
• lead to plasma leaving the capillaries and building
up in the pulmonary interstitium. When this occurs at such a rate that lymphatic drainage from the lung cannot keep up (lymphatic obstruction), flooding of the alveoli results. 1/18/2018 Acute Pulmonary Oedema 5 Symptoms • Shortness of breath • Tachypnea and tachycardia • Easy fatigue • Dizziness • Profuse diaphoresis • Cough • Pink, frothy sputum
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Staging of Pulmonary Oedema Three stages of PE can be distinguished based on the degree of fluid accumulation: • Stage 1 : all excess fluid can still be cleared by lymphatic drainage. • Stage 2 : characterized by the presence of interstitial edema. • Stage 3 : characterized by alveolar edema due to altered alveolar-capillary permeability • Mild: Only engorgement of pulmonary vasculature is seen. • Moderate: There is extravasation of fluid into the interstitial space due to changes in oncotic pressure. • Severe: Alveolar filling occurs.
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Types of pulmonary oedema • Cardiogenic • Non-cardiogenic
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Cardiogenic • Cardiogenic pulmonary edema (CPE) is defined as pulmonary edema due to increased capillary hydrostatic pressure secondary to elevated pulmonary venous pressure. CPE reflects the accumulation of fluid with a low- protein content in the lung interstitium and alveoli as a result of cardiac dysfunction.
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• In cardiogenic APO, an acute reduction in cardiac output associated with an increase in systemic vascular resistance (SVR) leads to back-pressure on the pulmonary vasculature, with resultant increased pulmonary capillary pressure. In most cases, the patient has a maldistribution of fluid rather than being fluid overloaded. They may, in fact, have a whole-body fluid deficit.
This understanding has led to a change in the management of this
condition, from the use of large doses of diuretics to a focus on vasodilators and non-invasive ventilation that reduce SVR and improve cardiac output. 1/18/2018 Acute Pulmonary Oedema 10 Pathophysiology of Cardiogenic APO
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1/18/2018 Acute Pulmonary Oedema 12 Examples included • Left ventricular failure: – Acute coronary syndromes – Arrhythmias – Pericarditis, myocarditis or endocarditis – Valve dysfunctions (eg. Aortic stenosis, mitral regurgitation) • Increase intravascular volume: – Fluid overload – Non-compliance with fluid restriction or diuretics – Renal failure • Pulmonary venous outflow obstruction: – Mitral valve stenosis 1/18/2018 Acute Pulmonary Oedema 13 Non-cardiogenic • In non-cardiogenic APO, pathological processes acting either directly or indirectly on the pulmonary vascular permeability. As a result, proteins leak from the capillaries, increase the interstitial oncotic pressure, so that it exceeds that of the blood and fluid is subsequently drawn from the capillaries. Injury to alveolar cells will also reduce their ability to clear this oedema fluid from the alveolar space. 1/18/2018 Acute Pulmonary Oedema 14 Examples included • High output states: – Septicemia – Anemia – Thyrotoxicosis • Systemic increase in vascular permeability: – Pancreatitis – Eclampsia – Disseminated intravascular coagulation – Burns • Toxins / environmental: – Immersion / submersion – Toxic inhalation – High altitude pulmonary oedema and decompression illness • Others: – Head injury or intracranial hemorrhage – Drugs (eg. NSAIDs, calcium channel blocker) – Pulmonary embolus Acute Pulmonary Oedema 1/18/2018 15 1/18/2018 Acute Pulmonary Oedema 16 1/18/2018 Acute Pulmonary Oedema 17 Clinical assessment - History • Usually a history of sudden-onset severe dyspnoea. • Recent occurrence of chest pain, a past history of ischaemic heart disease or congestive heart failure or an other causative factor is sought. • Details of current medication and compliance are also important.
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Clinical assessment - Examination • Vital sign: – High respiratory rate – Low oxygen saturation, reflecting hypoxia – Most are hypertensive or normotensive. (Hypotension indicates cardiogenic shock and a very poor prognosis). • Inspection: – Pale or cyanosed, sweaty (sometimes profusely) and frightened. – Strive to maintain an upright position at all costs and may be unable to sit still. – May cough up pink or white frothy sputum, adding to their feeling of drowning. – Use of the accessory muscles of respiration, and breathing is often noisy. – Raised jugular venous pressure (JVP) • Percussion – Dull • Auscultation – Third heart sound or gallop. – Signs of chronic heart failure should also be sought, as well as murmurs that may hint at the cause. – Fine crepitations, which are often extensive. – Other adventitial lung sounds, 1/18/2018 Acute including wheeze – so-called ‘cardiac asthma’. 19 Pulmonary Oedema Clinical investigations Electrocardiogram Imaging – Chest X-ray – Ultrasound Blood test – Haemoglobin – Electrolytes and ABG – Cardiac biomarkers • Brain or B-type natriuretic peptide (BNP) • N-terminal pro-brain natriuretic peptide (NT-proBNP) levels Oximetry Echocardiography Special Investigations: Cardiac catheterization/coronary angiography when acute intervention for acute myocardial ischaemia or infarction/valvular disease is anticipated. Swan Ganz catheter placement 1/18/2018 Acute Pulmonary Oedema 20 ECG • looking for acute ischaemia, especially evidence of ST-elevation myocardial infarction (STEMI)
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Chest X-ray
Cardiogenic Non-cardiogenic
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Chest X-ray
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1/18/2018 Acute Pulmonary Oedema 24 Echocardiogram • to identify structural abnormalities and assess LV systolic and diastolic dysfunction
Natriuretic peptides or their precursors (especially
BNP and NT-proBNP) • If available, this investigation is useful in the evaluation of patients presenting with acute dyspnoea in the urgent care setting in whom the clinical diagnosis of HF is uncertain. A low-normal concentration of this marker in an untreated patient makes the diagnosis of HF unlikely. Thus it is a useful “rule–out” test in doubtful cases.
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1/18/2018 Acute Pulmonary Oedema 26 Management • In all patients with APO, management strategies should provide supportive care to maximize cardiac output and oxygenation, followed by treatment of the underlying cause.
• Treatment of the patient with non-cardiogenic pulmonary
oedema consists of – removing the patient from the causative environment – supportive therapies aimed at maintaining oxygenation, including noninvasive and invasive ventilation in severe cases – treating the underlying cause.
These patients have lung injury and therefore low volume;
low pressure lung protective ventilation regimens should be followed. 1/18/2018 Acute Pulmonary Oedema 27 • Treatment of the patient with cardiogenic pulmonary oedema
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The initial management includes a combination of the following first line therapy: • Oxygen: 5 to 6 liters/minute, by mask with the aim of achieving oxygen – saturation of more than 95% in order to maximize tissue oxygenation and to prevent end organ dysfunction or multi organ failure. – Elective ventilation using non invasive positive pressure ventilation (Continuous Positive Airway Pressure [CPAP] or Bi-level Positive Airway Pressure [BiPAP]) should be considered early if necessary. – Should the oxygen saturation be inadequate or the patient develop respiratory muscle fatigue, then endotracheal intubation and mechanical ventilation is necessary.
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• Frusemide: (i.v.) 40 – 100mg. The dose should be – individualized depending on the severity of the clinical condition. – Administration of a loading dose followed by a continuous infusion has been shown to be more effective than repeated bolus injections alone. The dose should be titrated according to clinical response and renal function. • Morphine sulphate: (i.v.) 3 – 5 mg bolus (repeated if necessary, up to a total maximum of 10mg. It reduces pulmonary venous congestion and sympathetic drive. It is most useful in patients who are dyspnoeic and restless. Intravenous anti-emetics (metoclopramide 10mg or prochlorperazine 12.5mg) should be administered concomitantly. Care must be exercised in patients with chronic respiratory diseases. 1/18/2018 Acute Pulmonary Oedema 30 • Nitrates: If the BP is adequate (SBP > 100 mmHg), nitrates are indicated – as first line therapy in AHF51. It should be administered sublingually or intravenously. The i.v. route is more effective and preferable. Patients should be closely monitored for hypotension. This commonly occurs with concomitant diuretic therapy. – Studies have shown that the combination of i.v. nitrate and low dose frusemide is more efficacious than high dose diuretic treatment alone . – Extreme caution should be exercised in patients with aortic and mitral stenosis. – Nitrates are contraindicated in severe valvular stenosis