Severe Pulmonary edema - oxford

Question 1

causes of severe pulmonary edema

Answer 1

Cardiovascular, usually left ventricular failure (post-MI or ischaemic heart disease).
Also valvular heart disease, arrhythmias, and malignant hypertension
Valvular dysfunction (e.g., aortic regurgitation/stenosis, mitral regurgitation/stenosis)
Cardiac arrhythmia (e.g., atrial fibrillation

trauma, malaria, drugs

aspirin overdose or glue-sniffi ng/drug abuse

Fluid overload.

sepsis, acute pancreatitis
shock

blood transfusions

Neurogenic, eg head injury.

Question 2

what is the classification of pulmonary edema

Answer 2

cardiogenic
An accumulation of fluid in the lungs due to an increase in pulmonary capillary hydrostatic pressure

non cardiogenic
An accumulation of fluid in the lungs due to an increase in permeability of the pulmonary capillaries (fluid is rich in proteins)
eg sepsis acute pancreatitis

Question 3

what are the symptoms of asthma ?

Answer 3

Dyspnoea,
tacypnea
signs of hypoxia - cyanosis , tacycardia
orthopnoea (eg paroxysmal), pink frothy sputum
pulsus alternans

Usually sitting up and leaning forward.

physical
Rales or crackles on lung auscultation
Increased tactile fremitus
Dullness to percussion

In cardiogenic edema:
S3 gallop or murmurs on cardiac auscultation
Elevated jugular venous pressure
Peripheral edema

Question 4

what are the investigations that needs to be ordered ?

Answer 4

CXR

signs of  CARDIOGENIC pulmonary oedema:  
- cardiomegaly, 
- central edema
(usually bilateral) 
-small effusions at costophrenic angles
- pleural effusion 
- peribrocnhal cuffing 
- Kerley B lines (visible interlobar septal caused by pulmonary edema ).

Findings in noncardiogenic pulmonary edema
Patchy and peripheral edema
ground-glass opacities and consolidations with air bronchograms ( It refers to the presence of visible air-filled radiotransparent bronchi inside areas of alveolar consolidation)

• ECG: signs of MI, dysrhythmias.
• U&E, troponin, ABG.
• Consider echo.
• BNP - congestive heart failure high

renal function tests

albumin levels (≤ 3.4 g/dL) in patients with acute decompensated heart failure

↑ Lipase and/or amylase in patients with acute pancreatitis

!!!!!!!Pulmonary artery catheterization
Gold standard to determine the cause of pulmonary edema!!!!!!

Question 5

what is the management of pulmonary edema ?

Answer 5

A-E

high flow oxygen
Iv acess

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SIT THE PATIENT UPRIGHT

ECG - monitor and treat arrythmia such as AF

investigations whilst monitoring as said above

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Diamorphine 1.25–5mg IV slowly
Caution in liver failure and COPD

Furosemide 40–80mg IV slowly
Larger doses required in renal failure

GTN spray 2 puff s SL or 2 ≈ 0.3mg tablets SL
Don’t give if systolic BP <90mmHg

If systolic BP ≥100mmHg, start a nitrate infusion,
eg isosorbide dinitrate 2–10mg/h IVI; keep systolic BP ≥90mmHg

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If the patient is worsening:
• Further dose of furosemide 40–80mg

• Consider CPAP—improves ventilation by recruiting more alveoli, driving fluid outof alveolar spaces and into vasculature (get help before initiating!)
• Increase nitrate infusion if able to do so without dropping systolic BP <100mmHg

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If systolic BP <100mmHg, treat as cardiogenic shock

refer to ICU