EM · Pulmonary oedema
Pulmonary oedema
The pulmonary oedema from the fluid in the alveolar interstitium through the CARDIOGENIC (the raised pulmonary capillary pressure from the left ventricular failure — the ischaemia and the MI, the hypertensive crisis, the arrhythmia, the valve, the cardiomyopathy) distinguished from the NON-CARDIOGENIC (the ARDS, the increased permeability), the flash pulmonary oedema, the presentation (the dyspnoea, the orthopnoea, the frothy pink sputum, the bilateral crackles, the cardiac asthma), and the management (the upright position, the high-flow oxygen and the CPAP, the IV GTN, the IV furosemide, and the treat-the-cause).
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- The cardiogenic pulmonary oedema is the raised pulmonary capillary pressure from the left ventricular failure — the ischaemia and the MI, the hypertensive crisis, the arrhythmia, the valve failure, and the cardiomyopathy
- The CPAP or the NIV is the early intervention in the cardiogenic pulmonary oedema — it reduces the preload and the afterload and splints the alveoli
- The IV GTN infusion reduces the preload and the afterload; the IV furosemide diureses and the venodilates
- The BNP and the NT-proBNP and the echocardiography distinguish the cardiogenic from the non-cardiogenic (the ARDS)
- The acute coronary syndrome and the arrhythmia are the common triggers — the treat-the-cause (the PCI, the rate control) is essential
Meet the patient
A 78-year-old man lands in the resus bay at 4am, bolt upright and gasping, coughing up frothy pink sputum. RR 34, SpO2 86 per cent on room air, BP 168/96, atrial fibrillation at 126, and a wheeze right across both lung fields. The registrar reaches for the salbutamol nebuliser.[1][2]
This is not asthma — it is acute cardiogenic pulmonary oedema, with AF and ischaemia as the likely triggers. The single question that decides his first ten minutes is the one every examiner is really asking: what goes on his face, and in what order? Hold that question, and the ladder below slots straight into place.[1]
Etymology for viva gold: oedema comes from the Greek oidēma, "a swelling", from oidein, "to swell". The word has outlived its metaphor for two and a half millennia because the pathology — fluid where it should not be — is unchanged.[1]
References8ShowHide
- [1]Berbenetz N, Wang Y, Brown J, et al. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema Cochrane Database Syst Rev, 2019.PMID 30950507
- [2]Bello G, De Santis P, Antonelli M Non-invasive ventilation in cardiogenic pulmonary edema Ann Transl Med, 2018.PMID 30370282
- [3]Wu L, Rodriguez M, El Hachem K, et al. Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians J Clin Med, 2024.PMID 39124738
- [4]Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema N Engl J Med, 2008.PMID 18614781
- [5]Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition JAMA, 2012.PMID 22797452
- [6]Gil V, Domínguez-Rodríguez A, Masip J, et al. Morphine Use in the Treatment of Acute Cardiogenic Pulmonary Edema and Its Effects on Patient Outcome: A Systematic Review Curr Heart Fail Rep, 2019.PMID 31183779
- [7]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Eur Heart J, 2021.PMID 34447992
- [8]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Eur Heart J, 2023.PMID 37622666