11

Acute Pulmonary EdemaAcute Pulmonary Edema

22

DEFINISI EDEMA PARUDEFINISI EDEMA PARU

Terkumpulnya cairan ekstra vaskuler yg Terkumpulnya cairan ekstra vaskuler yg patologis di dalam paru(alveoli)patologis di dalam paru(alveoli)

Ok peningkatan tek.hidrostatik(Cardiogenic) Ok peningkatan tek.hidrostatik(Cardiogenic) atau tek.permeabilitas(Non Cardiogenic) atau tek.permeabilitas(Non Cardiogenic) pemb.darah kapiler paru.pemb.darah kapiler paru.

33

44

INHALATION/ASPIRATION

55

66

77

FISIOLOGI EDEMA PARUFISIOLOGI EDEMA PARU Ruang alveolar dipisahkan dari interstisium paru terutama Ruang alveolar dipisahkan dari interstisium paru terutama

oleh sel epitel alveoli tipe 1,dlm keadaan normal oleh sel epitel alveoli tipe 1,dlm keadaan normal membentuk suatu barrier yg relatif non-permeabel thd membentuk suatu barrier yg relatif non-permeabel thd aliran cairan dari interstisium ke rongga udara.aliran cairan dari interstisium ke rongga udara.

Fraksi yg besar di ruang interstisial dibentuk oleh kapiler Fraksi yg besar di ruang interstisial dibentuk oleh kapiler paru yg dindingnya terdiri atas satu lapis sel endotel diatas paru yg dindingnya terdiri atas satu lapis sel endotel diatas membran basal,sisanya merupakan jarigan ikat yg terdiri membran basal,sisanya merupakan jarigan ikat yg terdiri dari jaringan kolagen dan elastik,fibroblas,fagositik,dan dari jaringan kolagen dan elastik,fibroblas,fagositik,dan bbrp sel lain.bbrp sel lain.

FISIOLOGI EDEMA PARUFISIOLOGI EDEMA PARU

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

88

9

Microvascular fluid exchange in lung

small gaps/celahfty small gaps/celahfty between endothelial between endothelial

cellscells

tight junctionstight junctions

Peribronchovascular InterstitiumLymphatic Drainage

1010

Pulmonary EdemaPulmonary Edema(CXR/Foto Toraks)(CXR/Foto Toraks)

Interstitial pulmonary edemaInterstitial pulmonary edema– Poorly defined pulmonary vesselsPoorly defined pulmonary vessels– Visible lung fissuresVisible lung fissures– Septal linesSeptal lines– Thick bronchial wallsThick bronchial walls

Alveolar pulmonary edemaAlveolar pulmonary edema– Bilateral symmetric perihilar lung consolidationBilateral symmetric perihilar lung consolidation

Enlarged heart, Pleural effusion(Cardiogenic)Enlarged heart, Pleural effusion(Cardiogenic)

1111

Normal Chest PA and Lateral Normal Chest PA and Lateral RadiographsRadiographs

1212

Pulmonary EdemaPulmonary Edema

Normal pulmonary vessels

Interstitial pulmonary edema

Alveolar pulmonary edema

Septal (Kerley B) lines due to interstitial pulmonary edema are thickened interlobular septae

1313

Left Upper Lobe PneumoniaLeft Upper Lobe Pneumonia

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

14

CaseCase

62-year-old man with history of 62-year-old man with history of congestive heart failurecongestive heart failure 2 years ago 2 years agoProgressive dyspneaProgressive dyspnea, , nonproductive coughnonproductive cough & & low-grade feverlow-grade fever for 3 days for 3 days

Blood pressure: 95/55 mm HgBlood pressure: 95/55 mm Hg Heart rate: 110 beats / minuteHeart rate: 110 beats / minute

Temperature: 37.9°CTemperature: 37.9°CSaO2 in ambient air: 86%SaO2 in ambient air: 86%

Chest auscultation reveals Chest auscultation reveals rales(basah/kering)rales(basah/kering) and and rhonchirhonchi (halus)(halus)bilaterallybilaterallyChest radiograph shows Chest radiograph shows bilateral pulmonary infiltratesbilateral pulmonary infiltrates consistent with consistent with pulmonary edema and pulmonary edema and borderline enlargementborderline enlargement of the cardiac silhouette of the cardiac silhouette

Difficult to distinguish Difficult to distinguish because of similar because of similar

clinical manifestationsclinical manifestations

1515

Cause of acute pulmonary edema ?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 Difficult to distinguish because of similar clinical manifestationsclinical manifestations

16

Clinical ProblemClinical 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 cmH2O

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!!!

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 cmH2O

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!!!

1717

Microvascular fluid exchange in Microvascular fluid exchange in lunglung

small gaps between small gaps between endothelial cellsendothelial cells

tight junctionstight junctions

Peribronchovascular InterstitiumLymphatic Drainage

1818

Pulmonary EdemaPulmonary Edema

1919

DIFF.DIAGNOSIS OFDIFF.DIAGNOSIS OFPULMONARY EDEMAPULMONARY EDEMA

2020Disrup,mngacauknhjy

2121

A rapid increase in A rapid increase in hydrostatic hydrostatic pressurepressure in the pulmonary in the pulmonary

capillaries leading to increased capillaries leading to increased transvascular fluid filtrationtransvascular fluid filtration is is

the hallmark of acute the hallmark of acute cardiogenic or volume-overload cardiogenic or volume-overload edema. Increased hydrostatic edema. Increased hydrostatic

pressure in the pulmonary pressure in the pulmonary capillaries is usually due to capillaries is usually due to elevated pulmonary venous elevated pulmonary venous pressure from increased pressure from increased left left

ventricular end-diastolic ventricular end-diastolic pressure and left atrial pressure and left atrial

pressurepressure. .

LAP 18 ~ 25mmHgLAP 18 ~ 25mmHg

LAP > 25mmHgLAP > 25mmHgLAP:Left Atrial Pr.

2222

Noncardiogenic pulmonary Noncardiogenic pulmonary edema has a edema has a high protein high protein

contentcontent because the vascular because the vascular membrane is more permeable to membrane is more permeable to

the outward movement of the outward movement of plasma proteins. The net plasma proteins. The net

quantity ofquantity ofaccumulated pulmonary edema accumulated pulmonary edema

is determined by the balance is determined by the balance between the between the rate at which fluid rate at which fluid is filteredis filtered into the lung and the into the lung and the

rate at which fluidrate at which fluidis removedis removed from the air spaces from the air spaces

and lung interstitium.and lung interstitium.

IMPAIREDIMPAIRED

Impire mnggujhy

2323

Pulmonary Edema: PathophysiologyPulmonary Edema: PathophysiologyPulmonary Edema: PathophysiologyPulmonary Edema: Pathophysiology

A pathophysiologic condition, not a A pathophysiologic condition, not a diseasedisease– Fluid in and around alveoliFluid in and around alveoli– Interferes with gas exchangeInterferes with gas exchange– Increases work of breathingIncreases work of breathing

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

2424

Pulmonary EdemaPulmonary Edema

High Pressure (cardiogenic)High Pressure (cardiogenic) AMIAMI Chronic HTNChronic HTN MyocarditisMyocarditis

High Permeability (non-cardiogenic)High Permeability (non-cardiogenic) Poor perfusion, Shock, HypoxemiaPoor perfusion, Shock, Hypoxemia High Altitude, DrowningHigh Altitude, Drowning Inhalation/infection of pulmonary irritantsInhalation/infection of pulmonary irritants

2525

Cardiogenic Pulmonary Edema: Cardiogenic Pulmonary Edema: EtiologyEtiology

Left ventricular failureLeft ventricular failure Valvular heart diseaseValvular heart disease

– StenosisStenosis– InsufficiencyInsufficiency

Hypertensive crisis (high afterload)Hypertensive crisis (high afterload) Volume overloadVolume overload

Increased Pressure in Pulmonary Vascular Bed

2626

Pulmonary EdemaPulmonary Edema

High PermeabilityHigh Permeability– Disrupted alveolar-capillary membraneDisrupted alveolar-capillary membrane– Membrane allows fluid to leak into the interstitial Membrane allows fluid to leak into the interstitial

spacespace– Widened interstitial space impairs diffusionWidened interstitial space impairs diffusion

2727

Non-Cardiogenic Pulmonary Non-Cardiogenic Pulmonary Edema: EtiologyEdema: Etiology

Toxic inhalationToxic inhalation Near drowningNear drowning Liver diseaseLiver disease Nutritional deficienciesNutritional deficiencies LymphomasLymphomas High altitude pulmonary edemaHigh altitude pulmonary edema Adult respiratory distress syndromeAdult respiratory distress syndrome

Increased Permeability of Alveolar-Capillary Walls

2828

Pulmonary Edema: Signs Pulmonary Edema: Signs &Symptoms&Symptoms

Dyspnea on exertionDyspnea on exertion Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea OrthopneaOrthopnea Noisy, labored breathingNoisy, labored breathing Restlessness, anxietyRestlessness, anxiety Productive cough (frothy sputum)/berbusaProductive cough (frothy sputum)/berbusa Rales, wheezingRales, wheezing TachypneaTachypnea TachycardiaTachycardia

2929

EVALUATIONEVALUATION

天藍．地點：嘉義．攝影：杜漢祥

3030

HistoryHistory Interstitial edema Interstitial edema dyspneadyspnea and and tachypneatachypnea Alveolar flooding Alveolar flooding hypoxemiahypoxemia, , cough cough & expectoration of & expectoration of frothy frothy

edema fluidedema fluid

Focus on determining the underlying clinical disorderFocus on determining the underlying clinical disorder

CARDIOGENICCARDIOGENIC: : paroxysmal nocturnal dyspneaparoxysmal nocturnal dyspnea or or orthopneaorthopnea • Ischemia ± myocardial infarctionIschemia ± myocardial infarction• Exacerbation of chronic systolic or diastolic heart failureExacerbation of chronic systolic or diastolic heart failure• Dysfunction of the mitral or aortic valveDysfunction of the mitral or aortic valve• Volume overload should also be consideredVolume overload should also be considered

NONCARDIOGENICNONCARDIOGENIC: signs & symptoms of : signs & symptoms of infectioninfection, decrease in , decrease in level of level of consciousnessconsciousness associated with associated with vomiting, traumavomiting, trauma etc. etc.• Pneumonia, Sepsis, Aspiration of gastric contents, Major Pneumonia, Sepsis, Aspiration of gastric contents, Major

trauma associated with multiple blood-product transfusiontrauma associated with multiple blood-product transfusion

Unfortunately, the history is not always Unfortunately, the history is not always reliable.reliable.

3131

Physical ExaminationPhysical Examination S3 GallopS3 Gallop Heart murmurHeart murmur Elevated neck veinsElevated neck veins Peripheral edemaPeripheral edema Lung examinationLung examination Abdominal & Pelvic Abdominal & Pelvic Warm extremities VS Warm extremities VS

Cool extremitiesCool extremities

Relatively specific for Relatively specific for elevatedelevated LVEDP LVEDP & & LV dysfunctionLV dysfunction

Specificity: Specificity: 90 ~ 97%90 ~ 97% Sensitivity: 9 ~ 51%Sensitivity: 9 ~ 51%

Difficulty in clearly Difficulty in clearly identifying an S3 gallop identifying an S3 gallop & Mechanical ventilation & Mechanical ventilation

interfereinterfere

Stenosis / Regurgitation Stenosis / Regurgitation Cardiogenic ?Cardiogenic ?

Elevated neck veins, an Elevated neck veins, an enlarged and tender liver, enlarged and tender liver, and peripheral edema and peripheral edema

High CVP ?High CVP ?

Not SpecificNot Specific: hepatic / renal : hepatic / renal insufficiency, right heart insufficiency, right heart

failure, systemic infectionfailure, systemic infection

Abdominal, pelvic, and Abdominal, pelvic, and rectal examinations are rectal examinations are

important.important.

An intraabdominal crisis An intraabdominal crisis such as perforation of a such as perforation of a viscus can cause acute viscus can cause acute

lung injury with lung injury with noncardiogenic noncardiogenic

edemaedema..

Noncardiogenic VS Noncardiogenic VS CardiogenicCardiogenic

3333

Laboratory TestingLaboratory Testing ElectrocardiographyElectrocardiography and and Cardiac enzymeCardiac enzyme

Electrolytes, Serum osmolarityElectrolytes, Serum osmolarity and and Toxicology screenToxicology screen

Serum amylaseSerum amylase and and lipaselipase

Brain Natriuretic Peptide (BNP)Brain Natriuretic Peptide (BNP)• Secreted by Secreted by cardiac ventriclescardiac ventricles in response to in response to

wall stretch or increased intracardiac pressureswall stretch or increased intracardiac pressures

• Plasma BNP levels correlate with Plasma BNP levels correlate with LVEDPLVEDP and and pulmonary-artery occlusion pressurepulmonary-artery occlusion pressure

3434

Chest RadiographyChest Radiography

Enlargement of the peribronchovascular spaces

Kerley’s B lines

Air bronchograms

3636

Pulmonary Edema Pulmonary Edema

3737

Management of Non-Cardiogenic Management of Non-Cardiogenic Pulmonary EdemaPulmonary Edema

PositionPosition OxygenOxygen PPV / IntubationPPV / Intubation

– CPAPCPAP– PEEPPEEP

IV Access; Minimal fluid administrationIV Access; Minimal fluid administration Treat the underlying causeTreat the underlying cause

– Diuretics usually not helpful; May be harmfulDiuretics usually not helpful; May be harmful

TransportTransport

3838

Adult Respiratory Distress Adult Respiratory Distress SyndromeSyndrome

Non-cardiogenic pulmonary edemaNon-cardiogenic pulmonary edema A complication of:A complication of:

– Severe Trauma / ShockSevere Trauma / Shock– Severe infection / SepsisSevere infection / Sepsis– Bypass SurgeryBypass Surgery– Multiple blood transfusionsMultiple blood transfusions– Drug overdoseDrug overdose– AspirationAspiration– Decreased complianceDecreased compliance– HypoxemiaHypoxemia

3939

ARDS PathophysiologyARDS Pathophysiology

A condition resulting from A condition resulting from severesevere illness illness or injury and associated with a high or injury and associated with a high mortality ratemortality rate– Increased permeabilityIncreased permeability– Pulmonary edemaPulmonary edema– Surfactant destructionSurfactant destruction– AtelectasisAtelectasis– Decreased complianceDecreased compliance– HypoxemiaHypoxemia

4040

ARDS PresentationARDS Presentation

HistoryHistory– Recent hx of Recent hx of severesevere illness or injury illness or injury– Often already being treated for underlying Often already being treated for underlying

causecause

Exam FindingsExam Findings– DyspneaDyspnea– Evidence of pulmonary edemaEvidence of pulmonary edema– Poor oxygenationPoor oxygenation– Decreased lung complianceDecreased lung compliance

4141

ARDS ManagementARDS Management

Airway ManagementAirway Management– Endotracheal intubationEndotracheal intubation– SuctionSuction

Mechanical VentilationMechanical Ventilation– PEEPPEEP

ECG MonitoringECG Monitoring Treat underlying causeTreat underlying cause

– May require vasopressors for shockMay require vasopressors for shock

STEPWISE APPROACHSTEPWISE APPROACH漸．地點：仁義潭．攝影：杜漢祥

4343

In patients with an uncertain cause or possible multiple causes of edema, insertion of a pulmonary artery catheter may be necessary

THE END

Thank You Very Much~!!!Thank You Very Much~!!!