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Snapshot
  • A 65-year-old man presents to the emergency department for worsening shortness of breath over the course of 2 weeks. He noticed that his feet are swelling and that he feels short of breath when climbing the stairs or walking more than 2 blocks. Medical history is significant for a myocardial infarction approximately 1 month ago which he required a drug-eluting stent. Physical examination is notable for bibasilar crackles, jugular venous distension, and bilateral lower extremity edema. A chest radiograph is obtained, which demonstrates bilateral pleural effusion, cephalization, and Kerley lines. 
Introduction
  • Definition
    • pulmonary interstitium and airspace fluid accumulation
  • Types
    • cardiogenic
      • pulmonary edema secondary to an acute increase in left ventricular filling pressure and left atrial volume, which increases pulmonary capillary wedge pressure
      • causes of impaired left ventricular function
        • coronary artery disease
        • hypertension
        • valvular disease
        • dilated cardiomyopathy
        • metabolic conditions (e.g., hypothyroidism)
        • myocarditis
        • toxins
        • ventricular hypertrophy
        • outflow obstruction
      • impaired left ventricular contractility decreases cardiac output, which activates the renin-angiotensin-aldosterone and sympathetic nervous system
        • salt and water retention contribute to pulmonary edema 
    • noncardiogenic
      • pulmonary edema without evidence (pulmonary capillary wedge pressure ≤ 18 mmHg) 
      • causes include
        • acute respiratory distress syndrome
        • high altitude 
          • hypoxia, dyspnea, and dry cough when exposed to a high altitude
        • opioid overdose
Presentation
  • Symptoms
    • dyspnea
  • Physical exam
    • bibasilar inspiratory crackles
      • due to air expanding fluid-filled alveoli
    • rusty-colored sputum
      • due to rupture of pulmonary capillaries from elevated hydrostatic pressure
    • wheezing
      • due to peribronchiolar edema
      • "cardiac asthma"
Differential
  • Pneumonia
  • Mucous plugging 
    • diffusing opacification of the lung field from atelectasis without fluid accumulation
Imaging
  • Radiography of the chest
    • indication
      • initial imaging study in the evaluation of pulmonary edema
    • findings
      • cephalization (reflects an elevation in left atrial pressures)
      • Kerley lines
      • air bronchograms
      • pleural effusion
Studies
  • Making the diagnosis
    • based on the patient's clinical history and imaging findings demonstrating pulmonary edema
      • what is key is differentiating cardiogenic from non-cardiogenic causes of pulmonary edema
        • e.g., progressive dyspnea, weight gain, peripheral edema, crackles in the lung bases, and jugular venous distension suggest that the pulmonary edema is due to congestive heart failure
Treatment
  • Treatment directed at the underlying etiology
    • loop diuretics, BIPAP, nitroglycerin in patients with heart failure   

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