Cardiogenic Pulmonary Oedema

Overview

Pulmonary edema where the heart is to blame. Increases in pulmonary pressure (PCWP) are secondary to ineffective filling/pumping of the heart. This is the most common presentation of Congestive Heart Failure (CHF).

The patient can go into respiratory fatigue.

• Etiology of cardiogenic pulmonary edema
  • Congestive Heart Failure
  • Valvular Disease (Aortic and Mitral)
  • Arrhythmia
  • Myocarditis
• Etiology of non-cardiogenic pulmonary edema
  • Lymphatic obstruction (decreased drainage from the interstitium
  • Excess volume administration
  • Decreased oncotic pressure (low albumin state)
  • Damage to the lung itself (inflammatory process etc.)
• Cause of early pulmonary edema
  • Respiratory alkalosis (due to High respiratory rate)
• Cause of late pulmonary edema
  • Respiratory acidosis (due to respiratory fatigue)
• Signs and symptoms
  • Dyspnea
  • Cough
  • Pink frothy sputum
  • Anxiety
  • Chest Pain
  • Tachypnea
  • Tachycardia
  • Visible distress
  • Crackles
  • Wheezing
  • S3, S4 murmur
  • Cool extremities
  • Skin mottling
• Investigations
  • Labs
    • CBC
    • U/E/Cs
    • Liver Function Tests
    • BNP
  • Chest X-ray: acute or chronic (best initial step in a patient who does not need to be intubated)
  • Echocardiogram
  • EKG
• Emergency treatment
  • IV ACEi (Captopril)
  • IV loop diuretic (Furosemide)
  • IV nitroprusside or nitroglycerin
  • 100% O2 (face mask, CPAP, BiPAP, intubation if necessary)
  • Morphine
  • Identify and address the underlying cause ASAP
    • If systolic heart failure use Dobutamine
  • Sit patient upright
  • Reassurance

Typical presentations of Cardiogenic Pulmonary Edema

• The patient presents with worsening dyspnea on exertion, a history of high cholesterol, diabetes mellitus, smoking, CAD
  • Systolic CHF (HFrEF)
• The patient presents with worsening fatigue, dyspnea, and has a history of untreated Strep infection, and had a longstanding murmur
  • Mitral Valve Stenosis
• The patient presents with severe dyspnea and SOB and has a longstanding history of uncontrolled hypertension
  • Diastolic CHF (HFpEF)
• The patient is being hospitalized and is a few days post MI, develops sudden dyspnea, pink frothy sputum, and new systolic murmur
  • Papillary muscle rupture
• The patient is very tachycardic, presents with anxiety, chest pain, and SOB, and has an EKG that shows wide QRS complexes with no discernable P or T waves
  • Ventricular Tachycardia

Chest X-ray in pulmonary Edema

Chest X-ray will clue you in on whether the edema is cardiogenic or non-cardiogenic. History, presentation, labs, and often echo and EKG are needed for definitive diagnosis

• Chest X-ray findings in acute pulmonary oedema
  • Alveolar infiltrates: a must with every pulmonary edema (wheezing, hypoxia, etc.) – “Bat’s wings”
  • Kerley B lines: fluid infiltration onto pulmonary interstitium (needs a keen eye)
  • Edema prominent in lower lung fields: Dependent
  • Hilar obscurity: frequent
  • Blunted costophrenic angle:
  • Enlarged cardiac silhouette: chronic condition (systolic CHF; Chronic Valvular Heart disease)
  • Normal cardiac silhouette: diastolic CHF or acute condition (Valve rupture secondary to MI, Myocarditis, Arrhythmia, Volume overload)