Acute Pulmonary Oedema

Question 1

Definition?

Answer 1

Accumulation of fluid in the lung parenchyma leading to impaired gas exchange between air in alveoli and pulmonary capillaries.

Question 2

RF?

Answer 2

Age >70
Ht
Valve abnormalities
Non-compliance
CAD

Question 3

Ddx?

Answer 3

CPO-bilateral creps cold pale and clammy and murmurs
COPD-diffuse wheeze
dry and warm
Pneumonia-focal crepitations flushed 
PE-clear chest, dry skin
ILD
Asthma

Question 4

Epidemiology?

Answer 4

Age over 75

male

Question 5

Aetiology

Answer 5

ACS
arrhythmias
HT
Compression on heart
medications
CF
sepsis
RAS
PE
neurogenic
drowning

Question 6

CP?

Answer 6

• Fatigue
• Dyspnoea 
• Orthopnoea
• PND
• Pink, frothy sputum
• Ankle swelling
• Pulses alternana-switches bt fast and slow
signs of LHF and RHF

Question 7

Pathophysiology?

Answer 7

• In heart failure compensatory mechanisms maintain CO and BP-via increasing heart rate and increasing resistance by vasoconstriction
• RAAS-increases salt and fluid retention increasing EDV and preload, so more CO.
• But overtime the heart becomes over-dilated to this increased preload, meaning that there is a drop in contractility hence SV and CO.
• This means that there us a backflow of blood into the pulmonary veins , hence alveolar oedema.
This increases teh distance in the alveoli so less perfusion occurs, causing dyspnoea and orthopnoea/paroxysmal nocturnal dyspnoea as the fluid collects due to the force of gravity when lying down.

Question 8

Investigations first line?

Answer 8

ABCDE-vitals
• ABG-hypoxaemia, type 1 resp failure, type 2 if existing pathology
• Full blood count
• U and E-raised urea and creatinine, hyponatremia
• LFT
• INR-AF
• Mg, Ca,
• TFT
• Troponin
• ECG-ischaemia, infarction, LVH, arrhythmias
• CXR-

Question 9

Signs on CXR?

Answer 9

• Alveolar Oedema
• Bats wing hilar shadowing and Kerly B lines
• Cardiomegaly
• Diversion to upper lobes-PV distension
• Effusions-blunting of costophrenic angles

Question 10

Investigations second line?

Answer 10

Echo

Question 11

Management first line?

Answer 11

ABCDE
• Monitor for pulse oximeter, BP cuff, three-lead cardiac monitoring
• Airway-manoeuvres, supraglottic or definitive airways and suction sputum
• Oxygen-15L via non-rebreather mask to get to 94-98% (88-92 if COPD)

Question 12

M-second line?

Answer 12

• Furosemide-IV(2.5-10 mg)
• Morphine-IV-(2.5-10 mg)-dilate veins anf decrease preload
• GTN-dilate coronary arteries-not if sbp<90mmHg

Question 13

M-third line?

Answer 13

• CPAP (continuous positive airway pressure)
• 5cmH20 to 10
• High flow oxygen increasing functional residual capacity reducing work of breathing and so oedema driven back into circulation
• If in cardiogenic shock-no nitrates and fluid challenge of 250ml

Question 14

M-onwards?

Answer 14

• HDU referral
• Arterial line-BP monitoring and ABG-30 mins
• Central line-help CVP and oxygen stats and inotropic agents
• Cardiac and urine output monitoring
• Check fluid weight

Question 15

Complications?

Answer 15

death

Question 16

Prognosis depends on?

Answer 16

• Older
• Male
• Hypotension
• anaemic
• high troponin
• High sodium
Renal impairment