Pulmonary Edema

Pulmonary Edema is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

Fluid accumulation in the tissue and air spaces of the lungs causing impaired gas exchange and respiratory failure due to either failure of the left ventricle to remove blood adequately from pulmonary circulation or to an injury to the lung parenchyma or vasculature of the lung leading to inflammation and impaired gas exchange
  • Cardiogenic:
    • Abnormality in cardiac function leading to inadequate removal of fluid from the pulmonary circulation and inadequate tissue perfusion
    • May be assessed by echocardiogram
    • Most frequent cause of pulmonary edema
  • Noncardiogenic:
    • Increased alveolar–capillary membrane permeability and accumulation of fluid in the alveoli without a cardiac etiology
    • Acute respiratory distress syndrome (ARDS):
      • New onset respiratory symptoms
      • Bilateral pulmonary opacities
      • Symptoms not explained by cardiac etiology or volume overload
      • Severity dictated by PaO2/FiO2 ratio of ≤200 mm Hg with <100 mm Hg implying severe disease
      • May be caused by many different systemic pathologies ranging from sepsis to pancreatitis

Etiology

  • Cardiogenic etiologies:
    • Systolic heart failure:
      • Ischemic heart disease
      • Dilated cardiomyopathy
      • Takotsubo cardiomyopathy
      • Cardiac dysrhythmias
      • Sepsis with myocardial stunning
      • Medication overdose or noncompliance
      • Myocarditis
      • Myocardial contusion
    • Diastolic heart failure:
      • Mitral or aortic stenosis
      • Hypertrophic cardiomyopathy
      • Restrictive cardiomyopathy
      • Pericardial effusion or tamponade
      • Cardiac arrhythmias
    • Pressure overload:
      • Mitral or aortic stenosis
      • Severe hypertension
    • Volume overload:
      • Mitral or aortic regurgitation
      • Missed dialysis or acute renal failure
      • Blood transfusions or IV fluid
    • High-output heart failure:
      • Thyrotoxicosis
      • Anemia
      • Arteriovenous fistula
      • Wet beriberi
      • Sepsis
    • Congenital or rheumatic heart disease
    • Endocarditis
  • Noncardiogenic etiologies:
    • Negative pressure pulmonary edema:
      • Upper airway obstruction
      • Re-expansion pulmonary edema
    • Neurogenic pulmonary edema:
      • Seizure
      • Head trauma
      • Subarachnoid hemorrhage
    • Systemic:
      • Sepsis
      • Pneumonia
      • Pancreatitis
      • Disseminated intravascular coagulation
      • Uremia
      • Malignancy
    • Other:
      • Inhalation or aspiration
      • Pulmonary contusion
      • Narcotic or medication overdose
      • Immersion pulmonary edema
      • Acute respiratory distress syndrome
      • High altitude pulmonary edema
      • Hantavirus pulmonary syndrome
      • Strangulation or electrocution

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Basics

Description

Fluid accumulation in the tissue and air spaces of the lungs causing impaired gas exchange and respiratory failure due to either failure of the left ventricle to remove blood adequately from pulmonary circulation or to an injury to the lung parenchyma or vasculature of the lung leading to inflammation and impaired gas exchange
  • Cardiogenic:
    • Abnormality in cardiac function leading to inadequate removal of fluid from the pulmonary circulation and inadequate tissue perfusion
    • May be assessed by echocardiogram
    • Most frequent cause of pulmonary edema
  • Noncardiogenic:
    • Increased alveolar–capillary membrane permeability and accumulation of fluid in the alveoli without a cardiac etiology
    • Acute respiratory distress syndrome (ARDS):
      • New onset respiratory symptoms
      • Bilateral pulmonary opacities
      • Symptoms not explained by cardiac etiology or volume overload
      • Severity dictated by PaO2/FiO2 ratio of ≤200 mm Hg with <100 mm Hg implying severe disease
      • May be caused by many different systemic pathologies ranging from sepsis to pancreatitis

Etiology

  • Cardiogenic etiologies:
    • Systolic heart failure:
      • Ischemic heart disease
      • Dilated cardiomyopathy
      • Takotsubo cardiomyopathy
      • Cardiac dysrhythmias
      • Sepsis with myocardial stunning
      • Medication overdose or noncompliance
      • Myocarditis
      • Myocardial contusion
    • Diastolic heart failure:
      • Mitral or aortic stenosis
      • Hypertrophic cardiomyopathy
      • Restrictive cardiomyopathy
      • Pericardial effusion or tamponade
      • Cardiac arrhythmias
    • Pressure overload:
      • Mitral or aortic stenosis
      • Severe hypertension
    • Volume overload:
      • Mitral or aortic regurgitation
      • Missed dialysis or acute renal failure
      • Blood transfusions or IV fluid
    • High-output heart failure:
      • Thyrotoxicosis
      • Anemia
      • Arteriovenous fistula
      • Wet beriberi
      • Sepsis
    • Congenital or rheumatic heart disease
    • Endocarditis
  • Noncardiogenic etiologies:
    • Negative pressure pulmonary edema:
      • Upper airway obstruction
      • Re-expansion pulmonary edema
    • Neurogenic pulmonary edema:
      • Seizure
      • Head trauma
      • Subarachnoid hemorrhage
    • Systemic:
      • Sepsis
      • Pneumonia
      • Pancreatitis
      • Disseminated intravascular coagulation
      • Uremia
      • Malignancy
    • Other:
      • Inhalation or aspiration
      • Pulmonary contusion
      • Narcotic or medication overdose
      • Immersion pulmonary edema
      • Acute respiratory distress syndrome
      • High altitude pulmonary edema
      • Hantavirus pulmonary syndrome
      • Strangulation or electrocution

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