Respiratory: Pulmonary Oedema

Question 1

What is pulmonary oedema?

Answer 1

Accumulation of fluid in the parenchyma and air spaces of the lungs.

Most commonly as a result of heart failure and/or fluid overload.

Question 2

Typical symptoms of pulmonary oedema?

Answer 2

1) SOB
2) Pink frothy sputum

Question 3

Typical signs of pulmonary oedema?

Answer 3

1) tachypnoea

2) decreased O2 sats

3) Raised JVP

Question 4

An ABCDE approach should be used in severe pulmonary oedema.

Describe the assessment in ‘airway’

Answer 4

1) Can the patient talk?

If no:
a) Look for signs of airway compromise e.g. cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.

b) Open the mouth and inspect: obstructions e.g. secretions, foreign object

Question 5

Give some causes of airway compromise

Answer 5

1) inhaled foreign body

2) blood in airway: e.g. epistaxis, haematemesis and trauma

3) vomit/secretions in airway

4) soft tissue swelling: anaphylaxis and infection (e.g. quinsy, necrotising fasciitis).

5) local mass effect: e.g. tumours

6) laryngospasm: asthma, gastro-oesophageal reflux disease (GORD) and intubation

7) depressed level of consciousness e.g. opioid overdose, head injury, stroke

Question 6

Discuss possible interventions in ‘airway’

Answer 6

1) Head-tilt chin-lift manoeuvre

2) Jaw thrust

3) Oropharyngeal airway (Guedel)

4) Nasopharyngeal airway (NPA)

5) Others e.g. anaphylaxis management

6) CPR

Question 7

When would a jaw thrust be indicated over a head-tilt chin-lift manoeuvre?

Answer 7

If the patient is suspected to have suffered significant trauma with potential spinal involvement.

Question 8

Who should nasopharyngeal airways (NPA) not be used in?

Answer 8

Patients who may have sustained a skull base fracture (due to the small but life-threatening risk of entering the cranial vault with the NPA).

Question 9

Which type of airway adjuct is better tolerated in patients who are partly or fully conscious?

Answer 9

Nasopharyngeal airway (NPA)

Question 10

Discuss assessment in ‘breathing’

Answer 10

1) RR

2) O2 sats

3) Inspection: respiratory distress e.g. the use of accessory muscles and cyanosis

4) Palpation:
- trachea position
- apex beat
- chest expansion

5) auscultation of lung fields

6) percussion

Question 11

What RR is typically seen in pulmonary oedema?

Answer 11

Tachypnoea: indicates significant respiratory compromise.

Question 12

what does bradypnoea indicate in ABCDE?

Answer 12

Bradypnoea in the context of hypoxia is a sign of impending respiratory failure and the need for urgent critical care review.

Question 13

How does severe pulmonary oedema typically affect O2 sats?

Answer 13

Hypoxaemia is a typical clinical feature of pulmonary oedema.

Question 14

What can cause a displaced apex beat?

Answer 14

1) large pleural effusion
2) tension pneumothorax
3) right ventricular hypertrophy

Question 15

What auscultation findings can be seen in pulmonary oedema?

Answer 15

1) Reduced breath sounds and/or coarse crackles

2) Wheeze (‘cardiac asthma’)

Question 16

Discuss investigations in ‘breathing’

Answer 16

1) ABG
2) CXR

Question 17

Typical ABG findings in pulmonary oedema?

Answer 17

low PaO2 and low PaCO2

Question 18

What does a normal or raised PaCO2 indicate in pulmonary oedema?

Answer 18

Concerning as it indicates that the patient is tiring and failing to ventilate effectively.

Question 19

What may be seen on a CXR in pulmonary oedema?

Answer 19

1) bilateral peri-hilar shadowing

2) blunting of costophrenic angles

3) fluid in fissures (e.g. right horizontal fissure)

4) Kerley B lines

Question 20

Discuss interventions in ‘breathing’

Answer 20

1) O2: 15 litre non-rebreathe

2) Continuous positive airway pressure (CPAP)

3) CPR

Question 21

Who is CPAP considered in in pulmonary oedema??

Answer 21

Should be considered for patients who do not improve after supplemental oxygen and intravenous diuretics.

Question 22

What should make sure to do after every intervention in ABCDE?

Answer 22

Reassess

Question 23

Discuss assessment in ‘circulation’

Answer 23

1) pulse

2) BP

3) capillary refill time

4) fluid status assessment

5) auscultation of heart sounds

Question 24

Typical HR finding in pulmonary oedema?

Answer 24

Tachycardia

Question 25

Important BP notes in pulmonary oedema:

Answer 25

Patients with acute heart failure may be hypotensive –> important to check BP before administering diuretics! (can worsen hypotension).

Fluid resuscitation to correct the hypotension can be challenging given the potential to worsen pulmonary oedema.

As a result, patients who are hypotensive with pulmonary oedema need immediate critical care input.

Question 26

Typical CRT finding in pulmonary oedema?

Answer 26

Capillary refill time may be prolonged in pulmonary oedema if the patient is hypotensive.

Question 27

What does fluid status assessment involve in ABCDE?

Answer 27

1) Inspecting the oral mucosa for hydration

2) Capillary refill time assessment

3) Assessment of jugular venous pressure (JVP)

4) Review of the patient’s fluid input and output

Question 28

What does an elevated JVP indicate?

Answer 28

hypervolaemia (may be the reason for pulmonary oedema)

Question 29

What may soft or muffled heart sounds indicate on auscultation?

Answer 29

pericardial effusion

Question 30

What does a gallop rhythm indicate on auscultation?

Answer 30

A gallop rhythm is a feature of congestive heart failure which is a cause of pulmonary oedema.

Question 31

Investigations in ‘circulation’?

Answer 31

Insert at least one wide-bore intravenous cannula (14G or 16G)

1) Blood tests:
- FBC: anaemia, infectino
- U&Es: renal function, electrolytes
- LFTs: albumin (hypoalbuminaemia can result in oedema).
- CRP: inflammation
- Troponin: if considering acute myocardial infarction as the cause of acute heart failure
- BNP: heart failure

2) ECG:
- evidence of acute myocardial ischaemia
- ventricular hypertrophy
- arrhythmias

Question 32

Key intervention in ‘circulation’ in pulmonary oedema?

Answer 32

IV diuretics e.g. furosemide

Question 33

Should vasodilators (e.g. GTN) or opiates (e.g. morphine) be used in pulmonary oedema?

Answer 33

No.

Question 34

Discuss assessment in ‘disability’

Answer 34

1) Consciousness: AVPU scale

2) Pupils:
- size & symmetry
- direct & consensual pupillary responses

3) Blood glucose & ketones

4) Drug chart review e.g. opioids

5) Imaging

Question 35

Discuss assessment in ‘exposure’

Answer 35

1) inspection e.g. legs (oedema), skin

2) temperature

Question 36

What is cardiac asthma?

Answer 36

A condition caused by heart failure that leads to asthma-like symptoms, such as wheezing, coughing, and trouble breathing.

Due to build up of fluid in lungs (pulmonary oedema).

Question 37

Pulmonary oedema can be broadly classified as cardiogenic and non-cardiogenic.

What are the cardiogenic causes of pulmonary oedema?

Answer 37

1) Left HF: congestive cardiac failure

2) Mitral regurgitation

3) Aortic stenosis

4) Arrhythmias

5) Myocardial pathology e.g. myocarditis

Question 38

What are the non-cardiogenic causes of pulmonary oedema?

Answer 38

Can be remembered with: NOT CARDIAC

N: near drowning
O: O2 therapy/post-intubation pulmonary oedema
T: trauma/transfusion (TRALI: transfusion-related acute lung injury)

C: CNS: neurogenic pulmonary oedema
A: allergic alveolitis
R: renal failure
D: drugs
I: inhaled toxins
A: altitude: high altitude pulmonary oedema (HAPE), ARDS
C: contusion