Acute Pulmonary Edema

DEFINISI EDEMA PARU

Terkumpulnya cairan ekstra vaskuler yg
patologis di dalam paru(alveoli)
Ok peningkatan tek.hidrostatik(Cardiogenic)
atau tek.permeabilitas(Non Cardiogenic)
pemb.darah kapiler paru.

INHALATION/ASPIRATION

FISIOLOGI EDEMA PARU

Ruang alveolar dipisahkan dari interstisium paru terutama
oleh sel epitel alveoli tipe 1,dlm keadaan normal
membentuk suatu barrier yg relatif non-permeabel thd
aliran cairan dari interstisium ke rongga udara.
Fraksi yg besar di ruang interstisial dibentuk oleh kapiler
paru yg dindingnya terdiri atas satu lapis sel endotel diatas
membran basal,sisanya merupakan jarigan ikat yg terdiri
dari jaringan kolagen dan elastik,fibroblas,fagositik,dan
bbrp sel lain.

FISIOLOGI EDEMA PARU

Faktor penentu yg penting dalam
pembentukan cairan ekstra seluler adalah
perbedaan tek.hidrostatik dan onkotik dalam
lumen kapiler dan ruang interstisial,serta
permeabilitas sel endotel thd air,dan
molekul besar,spt protein plasma.Faktorfaktor penentu ini di jabarkan dlm hukum
starling.
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tight junctions

Microvascular fluid exchange in lung

small gaps/celahfty
between endothelial
cells

Peribronchovascular
Lymphatic
Interstitium
Drainage
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Pulmonary Edema
(CXR/Foto Toraks)
Interstitial pulmonary edema
Poorly defined pulmonary vessels
Visible lung fissures
Septal lines
Thick bronchial walls

Alveolar pulmonary edema

Bilateral symmetric perihilar lung consolidation

Enlarged heart, Pleural effusion(Cardiogenic)

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Normal Chest PA and Lateral

Radiographs

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Pulmonary Edema

Normal pulmonary vessels

Interstitial pulmonary edema
Alveolar pulmonary edema

Septal (Kerley B) lines due to interstitial pulmonary

edema are thickened interlobular septae
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Left Upper Lobe Pneumonia

27-year-old man with productive cough, dyspnea, and fever

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Case
62-year-old man with history of congestive heart failure 2 years ago
Progressive dyspnea, nonproductive cough & low-grade fever for 3 days
Blood pressure: 95/55 mm Hg
Heart rate: 110 beats / minute
Temperature: 37.9C
SaO2 in ambient air: 86%
Chest auscultation reveals rales(basah/kering) and rhonchi
(halus)bilaterally
Chest radiograph shows bilateral pulmonary infiltrates consistent with
pulmonary edema and borderline enlargement of the cardiac silhouette
Difficult to distinguish
because of similar
clinical manifestations

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Cause of acute pulmonary edema ?

Cardiogenic pulmonary edema

Hydrostatic or Hemodynamic edema

Non-cardiogenic pulmonary edema

Increased-permeability pulmonary edema, acute lung injury or

acute respiratory distress syndrome

Difficult to distinguish because of similar

clinical manifestations
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Clinical Problem

Cardiogenic pulmonary edema

Diuretics and afterload reduction

Underlying cause: coronary revascularization etc.

Non-cardiogenic pulmonary edema

Low tidal volume (6 ml / kg)

Plateau airway pressure less than 30 cmH 2O
Lung-protective strategy of ventilation reduces
mortality in patients with acute lung injury.

Severe sepsis:

recombinant activated protein C and low-dose

hydrocortisone

Prompt diagnosis of the cause!!!

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tight junctions

small gaps between

endothelial cells
Microvascular fluid exchange in
lung

Peribronchovascular
Lymphatic
Interstitium
Drainage
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Pulmonary Edema

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DIFF.DIAGNOSIS OF
PULMONARY EDEMA

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Disrup,mngacauknhjy

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A rapid increase in hydrostatic

pressure in the pulmonary
capillaries leading to increased
transvascular fluid filtration is
the hallmark of acute
cardiogenic or volume-overload
edema. Increased hydrostatic
pressure in the pulmonary
capillaries is usually due to
elevated pulmonary venous
pressure from increased left
ventricular end-diastolic
pressure and left atrial
pressure.

LAP 18 ~ 25mmHg

LAP:Left Atrial Pr.

LAP > 25mmHg

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Noncardiogenic pulmonary
edema has a high protein
content because the vascular
membrane is more permeable to
the outward movement of
plasma proteins. The net
quantity of
accumulated pulmonary edema
is determined by the balance
between the rate at which fluid
is filtered into the lung and the
rate at which fluid
is removed from the air spaces
and lung interstitium.

IMPAIRED

Impire mnggujhy

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Pulmonary
Pulmonary Edema:
Edema: Pathophysiology
Pathophysiology
A pathophysiologic condition, not a
disease

Fluid in and around alveoli

Interferes with gas exchange
Increases work of breathing

Two Types
Cardiogenic (high pressure)
Non-Cardiogenic (high permeability)

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Pulmonary Edema
High Pressure (cardiogenic)
AMI
Chronic HTN
Myocarditis

High Permeability (non-cardiogenic)

Poor perfusion, Shock, Hypoxemia
High Altitude, Drowning
Inhalation/infection of pulmonary irritants

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Cardiogenic Pulmonary Edema:

Etiology
Left ventricular failure
Valvular heart disease
Stenosis
Insufficiency

Hypertensive crisis (high afterload)

Volume overload

Increased Pressure in Pulmonary Vascular

Bed
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Pulmonary Edema
High Permeability
Disrupted alveolar-capillary membrane
Membrane allows fluid to leak into the interstitial
space
Widened interstitial space impairs diffusion

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Non-Cardiogenic Pulmonary
Edema: Etiology

Toxic inhalation
Near drowning
Liver disease
Nutritional deficiencies
Lymphomas
High altitude pulmonary edema
Adult respiratory distress syndrome

Increased Permeability of Alveolar-Capillary

Walls
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Pulmonary Edema: Signs

&Symptoms

Dyspnea on exertion
Paroxysmal nocturnal dyspnea
Orthopnea
Noisy, labored breathing
Restlessness, anxiety
Productive cough (frothy sputum)/berbusa
Rales, wheezing
Tachypnea
Tachycardia
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EVALUATION

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History

Interstitial edema dyspnea and tachypnea

Alveolar flooding hypoxemia, cough & expectoration of frothy
edema fluid

Focus on determining the underlying clinical disorder

Unfortunately,
the history is not always reliable.

CARDIOGENIC: paroxysmal nocturnal dyspnea or orthopnea

Ischemia myocardial infarction
Exacerbation of chronic systolic or diastolic heart failure
Dysfunction of the mitral or aortic valve
Volume overload should also be considered
NONCARDIOGENIC: signs & symptoms of infection, decrease in
level of consciousness associated with vomiting, trauma etc.
Pneumonia, Sepsis, Aspiration of gastric contents, Major trauma
associated with multiple blood-product transfusion
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Physical Examination

S3 Gallop
Heart murmur
Elevated neck veins
Peripheral edema
Lung examination
Abdominal & Pelvic
Warm extremities VS
Cool extremities

Relatively specific for

elevated
LVEDP
Stenosis
/ Regurgitation
& Cardiogenic
LV dysfunction
?
Specificity:
90veins,
~ 97%
Elevated
neck
an
Abdominal,
pelvic,
and
Sensitivity:
9 ~ 51%
enlarged
and tender
liver,
rectal
examinations
are
and peripheral
edema
important.
Difficulty
in clearly
High CVP
?
identifying
an S3 gallop
An
intraabdominal
crisis
Mechanical
ventilation
Not&
Specific
: hepatic
/ renal
such
as perforation
of a
Noncardiogenic
VS
interfere
insufficiency,
right
heart
viscus can cause acute
failure,
systemic
Cardiogenic
lung
injuryinfection
with
noncardiogenic 31
edema.

Laboratory Testing

Electrocardiography and Cardiac enzyme

Electrolytes, Serum osmolarity and Toxicology screen

Serum amylase and lipase

Brain Natriuretic Peptide (BNP)

Secreted by cardiac ventricles in response to

wall stretch or increased intracardiac pressures
Plasma BNP levels correlate with LVEDP and
pulmonary-artery occlusion pressure
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Chest Radiography

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Enlargement of the
peribronchovascular
spaces
Kerleys B lines

Air bronchograms

Pulmonary Edema

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Management of Non-Cardiogenic
Pulmonary Edema
Position
Oxygen
PPV / Intubation
CPAP
PEEP

IV Access; Minimal fluid administration

Treat the underlying cause
Diuretics usually not helpful; May be harmful

Transport
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Adult Respiratory Distress

Syndrome
Non-cardiogenic pulmonary edema
A complication of:

Severe Trauma / Shock

Severe infection / Sepsis
Bypass Surgery
Multiple blood transfusions
Drug overdose
Aspiration
Decreased compliance
Hypoxemia

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ARDS Pathophysiology
A condition resulting from severe illness
or injury and associated with a high
mortality rate
Increased permeability
Pulmonary edema
Surfactant destruction
Atelectasis
Decreased compliance
Hypoxemia
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ARDS Presentation
History
Recent hx of severe illness or injury
Often already being treated for underlying cause

Exam Findings
Dyspnea
Evidence of pulmonary edema
Poor oxygenation
Decreased lung compliance

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ARDS Management
Airway Management
Endotracheal intubation
Suction

Mechanical Ventilation
PEEP

ECG Monitoring
Treat underlying cause
May require vasopressors for shock
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STEPWISE APPROACH

THE END
In patients with an uncertain cause or possible multiple causes of
edema, insertion of a pulmonary artery catheter may be necessary
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Thank You Very Much~!!!