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 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 DIAGNOSIS 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