Pulmonary oedema
Theory
Pulmonary oedema is effusion of serous fluid into the alveoli
and interstitial tissue of the lungs.
When hydrostatic pressure of pulmonary capillaries exceeds the osmotic pressure of plasma, fluid moves from the capillaries into the alveoli. This results in an impaired ability to oxygenate the blood and, ultimately, cardiorespiratory arrest.
Treatment is aimed at combating the increasing fluid in the lung spaces and maintaining oxygen delivery to the tissues.
Immediate intern management
Attend patient and make rapid assessment.
If patient unconscious/arrest
- Tell nursing staff to call Code Blue then move to head end of bed.
- Perform triple manoeuvre – chin lift, jaw thrust, head tilt.
- Clear mouth – suction secretions.
- Insert Guedel airway and bag and mask.
- Check pulse and if arrested start CPR.
If patient conscious/pre-arrest
- Call Code Blue.
- Oxygen by mask, continuous pulse oximetry.
- Sit patient up.
- Obtain IV trolley and insert IV line while taking blood.
- Give IV frusemide 40 mg (if patient on regular dose of frusemide then double it; if frusemide naive you can give 20 mg).
- Apply glyceryl trinitrate topically. Use a 5 mg patch for naive patients but a higher dose for patients already receiving a patch.
- Give IV morphine in 0.5–1 mg, 5 mg aliquots waiting 5 minutes between each aliquot.
- ECG – look for any ECG changes of ischaemia.
- Notify senior medical staff if not present already (medical registrar/ICU registrar).
- Consider non-invasive ventilation (CPAP).
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Clinical features (obtain rapidly)
History
- Basic information about patient
- Shortness of breath
- SOBOE
- Chest pain
- Symptoms of CCF (PND, SOA, orthopnoea)
- History of IHD, past AMI
- Fluid balance
Examination
- Vital signs
- Oxygen saturations
- Sweaty, anxious
- Raised JVP
- Crackles throughout lung fields or wheeze
- Cardiac murmur or added heart sounds S3, S4
- Swelling of ankles, peripheral oedema
Causes
- Cardiogenic
- AMI
- Acute valvular disorder
- Volume overload
- Iatrogenic fluid administration (especially post-op in the elderly)
- Renal failure
- Other
- ARDS
- PE
- Altitude
- Eclampsia
- Neurogenic (post convulsions/seizures)
- Post OD
- Non-compliance with therapy
Investigations
Emergency:
- ECG
- CXR
- Upper lobe venous diversion
- Prominent pulmonary vasculature
- Kerly B Lines
- ABG
- Basic blood tests including cardiac enzymes
Secondary:
- Echocardiography – ? valvular disease
- Stress tests
Definitive management – depends on cause
- Above management plus further morphine/frusemide as required to produce a diuresis
- Nitrates (50 mg – 25 mg GTN patch)
- As long as no history of aortic stenosis, and patient has good BP >110 systolic
- Maintain oxygen delivery by maintaining oxygen saturations:
- By mask
- Non-invasive ventilation (CPAP)
- Intubation and ventilation
- If patient fails to make a prompt response then should be transferred to ICU for invasive monitoring:
- Central venous line
- Arterial line
- Insert indwelling catheter for accurate measurement of fluid balance
- Commence fluid balance chart +/- daily patient weights
- Identify and treat underlying cause
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