Severe Pulmonary Oedema

Question 1

What causes PO?

1. Inc. pulmonary pressure
2. Inc pulmonary permeability

Answer 1

• `Heart
  
  • CAD (MI, ACS)
  • Cx of ACS
  • Arrythmias
  • valvular diseases
  • Hypertensive crisis
  • Acute PE
  • LAMyxoma
  • cardiac tamponade
• Renal
  
  • AKI, CKD
  • RAS
• Others
  
  • Liver failure
  • ARDS
  • High altitude
  • Sepsis
  • Aspirin overdoe

Question 2

What are the Cx of ACS?

Answer 2

• Rupture of interventricular septum
• Mitral valve chordal rupture

Question 3

What are the two types of PO?

Answer 3

• Cardiogenic PO
  
  • elevated pulmonary capillary pressure from left-sided heart failure
• Noncardiogenic PO
  
  • minimal elevation of pulmonary capillary pressure
  • oedema caused by changes in vascular permeability

Question 4

What are the Sx for PO?

Answer 4

• Dyspnoea
• Orthopnoea
• Pink frothy sputum
• Nausea
• Anxious

Question 5

What are the signs of PO?

Answer 5

• Respiratory distress
• Pale
• Sweaty
• Tachypnoeic
• tachycardic
• +/- Cyanosed, raised JVP
• Basal rales or fine crackles
• O2 sats <90
• Gallop rhythm (3rd heart spund)
• If RHF - check hepatomegaly or perioheral oedema

Question 6

What are the differentials for PO?

Answer 6

• Asthma
• COPD
• Pneumonia

Question 7

What Ix would you order for PO?

Answer 7

• Bedside
  
  • ECG - signs of MI, dysrhythmias, LVH
  • Urinary catheter - measure fluid balance
• Bloods
  
  • U&E, ABG, troponin, BNP, NT-pro-BNP
• Imaging
  
  • CXR
  • TTE

Question 8

What are the signs of PO on CXR?

Answer 8

• Cardiomegaly
• Small pleural effusion
• Kerley B line
• Fluid in lung fissures
• Bat wing sign (Patchy oerihilar shadowing) > alveolar oedema

Question 9

What are the normal levels of BNP and NT-pro-BNP?

Answer 9

• < 100ng/L
• < 300ng/L

Question 11

What is the function of BNP?

Answer 11

• relax the smooth muscle in blood vessels
• acts on the kidneys as a diuretic to promote the excretion of more water in the urine

Question 12

What causes a raise in BNP?

Answer 12

• Tachycardia
• Sepsis
• Pulmonary embolism
• Renal impairment
• COPD

Question 13

How would you Mx PO?

Answer 13

• Sit pt upright
• High flow
• IV cannula access
• Diamorphine 1.25-5mg/morphine 5-10mg IV slowly
• Furosemide 40-80mg IV slowly
• Nitrates
  
  • give if systolic BP >90mmHg
  • if sublingual: 2 puffs
  • if buccal isosorbide dinitrate: 1-3mg

Question 14

What will you do if the pt gets worse after initial Mx?

Answer 14

• Further dose Furosemide 40-80mg
• Consider CPAP
• Increase nitrate infusion w/o dropping systolic BP <100mmHg
• Consider alternative diagnoses
  
  • HTN HF, aortic dissection, PE, pnuemonia