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Updated: Dec 24 2021

Pulmonary Edema

  • 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
    • 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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