View source for Pulmonary edema

{{Infobox_Disease |
  Name           = Pulmonary edema |
  Image          = pulmonary edema.gif|
  Caption        = Chest x-ray showing pulmonary edema|
  DiseasesDB     = 11017 |
  ICD10          = {{ICD10|J|81||j|80}} |
  ICD9           = {{ICD9|514}} |
  ICDO           = |
  OMIM           = |
  MedlinePlus    = 000140 |
  eMedicineSubj  = med |
  eMedicineTopic = 1955 |
  eMedicine_mult = {{eMedicine2|radio|581}} | 
}}
{{SI}}
{{WikiDoc Cardiology Network Infobox}}
{{CMG}}

'''Associate Editor-In-Chief:''' {{CZ}}

{{Editor Join}}

==Overview==
'''Pulmonary [[edema]]''' (American English) or oedema (British English) is swelling and/or fluid accumulation in the [[lung]]s. It leads to impaired gas exchange and may cause [[respiratory failure]]. It is due to either [[failure of the heart]] to remove fluid from the lung circulation ("cardiogenic pulmonary edema"), or due to a direct injury to the lung [[parenchyma]] ("noncardiogenic pulmonary edema").<ref name=Ware>Ware LB, Matthay MA. Acute pulmonary edema. ''N Engl J Med'' 2005;353:2788-96. PMID 16382065.</ref> Differential Diagnosis of Pulmonary edema

==Differential diagnosis of causes of pulmonary edema==
Pulmonary edema is either due to direct damage to the tissue or as a result of inadequate functioning of the heart or circulatory system.

===Cardiogenic===

* Severe [[cardiac arrhythmia|arrhythmias]] ([[tachycardia]]/fast heartbeat or [[bradycardia]]/slow heartbeat)
* [[Arteriovenous malformation]] 
* [[Anomalous pulmonary venous return]]
* [[Aortic Regurgitation]]
* [[Aortic Stenosis]]
* [[Arrhythmia]]
* [[Cardiomyopathy]]
* Congenita pulmonary venous stenosis
* [[Congestive heart failure]]
* [[Coronary Heart Disease]]
* [[Hypertensive crisis]]
* [[Left Heart Failure]]
* Left-to-Right Shunt
* [[Mitral Regurgitation]]
* [[Mitral Stenosis]]
* [[Myocarditis]]
* [[Pericardial Disease]]. [[Pericardial effusion]] with tamponade
* ST elevation [[MI]] with [[left ventricular failure]]

===Non-cardiogenic===
This form is contiguous with ARDS ([[acute respiratory distress syndrome]]):

* Acute Bronchial [[Asthma]]
* [[Acute Renal Failure]]
* Bacterial toxins
* Blood [[Transfusions]]
* [[Burns]]
* Chronic [[mediastinitis]]
* Decompression sickness
* [[Disseminated Intravascular Coagulation]]
* [[Drowning]]
* [[Drugs]]
* Fibrotic/inflammatory disease
* Fluid overload, e.g. from [[renal failure|kidney failure]]
* Gastric content [[aspiration]]
* [[Goodpasture's Syndrome]]
* [[High altitude sickness]]. Ascent to high altitude occasionally causes [[high altitude pulmonary edema]] (HAPE)<ref>{{cite web | author=M Bates | title=High altitude pulmonary edema| url=http://www.altitude.org/hape_altitude.htm| publisher=Apex (Altitude Physiology Expeditions) | accessdate=2007-03-06}}</ref>
* [[Hyperhydration]]
* [[Hypoalbuminemia]] / Albumin deficiency
* [[Idiopathic Venoocclusive Disease]]
* Inhalation of toxic gases
* [[Infection]]
* [[Leukemia]]
* [[Malaria]]
* Miliary [[Tuberculosis]]
* Neurogenic, e.g. [[subarachnoid hemorrhage]]
* [[Pheochromocytoma]]
* [[Pneumonia]]
* Pulmonary contusion, i.e. high-energy trauma
* [[Pulmonary Embolism]]
* Reexpansion, i.e. post [[pneumonectomy]] or large volume [[thoracentesis]]
* Reperfusion injury, i.e. postpulmonary thromboendartectomy or [[lung transplantation]]
* [[Sepsis]]
* [[Shock]]
* [[Toxic Shock Syndrome]]
* Multi[[trauma]], e.g. motor vehicle accident
* Upper airway obstruction
* [[Uremia]]

===Complete Differential Diagnosis of the Causes of Pulmonary Edema===
(By organ system)
{|style="width:70%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" |  
Severe [[cardiac arrhythmia|Arrhythmias]] ([[tachycardia]]/fast heartbeat or [[bradycardia]]/slow heartbeat),[[Arteriovenous malformation]],[[Anomalous pulmonary venous return]], [[Aortic Regurgitation]], [[Aortic Stenosis]], [[Arrhythmia]], [[Cardiomyopathy]], Congenital [[pulmonary vein]] stenosis, [[Congestive heart failure]], [[Coronary Heart Disease]], [[Hypertensive crisis]], [[Left Heart Failure]], Left-to-Right Shunt, [[Mitral Regurgitation]], [[Mitral Stenosis]], [[Myocarditis]], [[Pericardial Disease]], [[Pericardial effusion]] with tamponade, ST elevation [[MI]] with [[left ventricular failure]]
|-
|-bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
|bgcolor="Beige"|  
[[Chemotherapy]]
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"|  
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"|  
A variety of [[Drugs]], particularly [[Chemotherapeutic agents]] such as anthracyclines
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"|  
[[Upper airway obstruction]]
|- 
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"|  
[[Pheochromocytoma]]
|- 
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"|  
[[High altitude sickness]]. Ascent to high altitude occasionally causes [[high altitude pulmonary edema]] (HAPE)<ref>{{cite web | author=M Bates | title=High altitude pulmonary edema| url=http://www.altitude.org/hape_altitude.htm| publisher=Apex (Altitude Physiology Expeditions) | accessdate=2007-03-06}}</ref>, Inhalation of toxic gases such as amonia, [[Water intoxication]]
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"|  
Gastric content [[aspiration]]
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"|  
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"|  
Blood [[Transfusions]], [[Idiopathic Venoocclusive Disease]], 
[[Disseminated Intravascular Coagulation]], [[Leukemia]]
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"|  
[[Hyperhydration]], Blood [[Transfusions]], [[High altitude sickness]]. Ascent to high altitude occasionally causes [[high altitude pulmonary edema]] (HAPE)<ref>{{cite web | author=M Bates | title=High altitude pulmonary edema| url=http://www.altitude.org/hape_altitude.htm| publisher=Apex (Altitude Physiology Expeditions) | accessdate=2007-03-06}}</ref>
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"|  
Bacterial toxins, [[Malaria]], Miliary [[Tuberculosis]], [[Sepsis]], [[Toxic Shock Syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"|  
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"|  
Neurogenic, e.g. [[Subarachnoid hemorrhage]]
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
|bgcolor="Beige"|  
[[Hypoalbuminemia]] / [[Albumin]] deficiency, [[Water intoxication]]
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"|  
[[Toxic Shock Syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"|  
[[Chemotherapy]]
|-
|-bgcolor="LightSteelBlue"
| '''Opthalmologic'''
|bgcolor="Beige"|  
|-
|-bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
|bgcolor="Beige"|  
[[Chemotherapy]], [[Water intoxication]]
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"|  
[[Psychogenic polydipsia]] with [[hyperhydration]], [[Water intoxication]]
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"|  
Acute Bronchial [[Asthma]], [[Drowning]], Gastric content [[aspiration]], [[Mediastinitis]],[[Pneumonia]], [[Pulmonary contusion]], [[Pulmonary embolism]], Reexpansion, i.e. post [[pneumonectomy]] or large volume [[thoracentesis]], Reperfusion injury, i.e. postpulmonary thromboendartectomy or [[lung transplantation]], [[Upper airway obstruction]]
|-
|-bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|bgcolor="Beige"|  
[[Acute Renal Failure]], [[Uremia]]
|-
|-bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"|  
[[Goodpasture's Syndrome]]
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"|  
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"|  
[[Drowning]], [[Burns]], Inhalation of toxic gases, [[Pulmonary contusion]], [[Trauma]]
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"|  
[[Acute Renal Failure]], [[Uremia]]
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"|  
[[Decompression sickness]], [[Shock]]
|-
|}

==Signs and symptoms==
Symptoms of pulmonary edema include [[shortness of breath|difficulty breathing]], [[haemoptysis|coughing up blood]], [[diaphoresis|excessive sweating]], [[anxiety]] and [[pallor|pale skin]]. A classical sign of pulmonary edema is the production of pink frothy sputum. If left untreated, it can lead to coma and even death, generally due to its main complication of [[Hypoxia (medical)|hypoxia]].

If [[pulmonary edema]] has been developing gradually, symptoms of fluid overload may be elicited. These include [[nocturia]] (frequent urination at night), ankle [[edema]] (swelling of the legs, generally of the "pitting" variety, where the skin is slow to return to normal when pressed upon), [[orthopnea]] (inability to lie down flat due to breathlessness) and [[paroxysmal nocturnal dyspnea]] (episodes of severe sudden breathlessness at night).

==Diagnosis==
[[Pulmonary edema]] is generally suspected due to findings in the medical history, such as previous cardiovascular disease, and [[physical examination]]: end-inspiratory crackles (sounds heard at the end of a deep breath) on auscultation (listening to the breathing through a [[stethoscope]]) are characteristic for pulmonary edema. The presence of a third heart sound (S3) is predictive of cardiogenic pulmonary edema.<ref name=Ware/>

Blood tests are generally performed for [[electrolyte]]s ([[sodium]], [[potassium]]) and markers of [[renal function]] ([[creatinine]], [[urea]]). [[Liver enzyme]]s, inflammatory markers (usually [[C-reactive protein]]) and a [[complete blood count]] as well as [[coagulation]] studies (PT, aPTT) are typically requested. [[Brain natriuretic peptide|B-type natriuretic peptide]] (BNP) is available in many hospitals, especially in the US, sometimes even as a point-of-care test. Low levels of BNP (<100 pg/ml) make a cardiac cause very unlikely.<ref name=Ware/>

The diagnosis is confirmed on [[X-ray]] of the lungs, which shows increased fluid in the alveolar walls. [[Kerley B lines]], increased vascular filling, [[pleural effusion]]s, upper lobe diversion (increased blood flow to the higher parts of the lung) may be indicative of cardiogenic pulmonary edema, while patchy alveolar infiltrates with air bronchograms are more indicative of noncardiogenic edema<ref name=Ware/>

Low [[oxygen saturation]] and disturbed [[arterial blood gas]] readings may strengthen the diagnosis and provide grounds for various forms of treatment. If urgent [[echocardiography]] is available, this may strengthen the diagnosis, as well as identify valvular heart disease. In rare occasions, insertion of a [[Swan-Ganz catheter]] may be required to distinguish between the two main forms of pulmonary edema.<ref name=Ware/>



==Treatment==

Depends on the cause, but focuses on maximizing respiratory function and removing the cause. When circulatory causes have led to pulmonary edema, treatment with intravenous nitrates ([[Glyceryl trinitrate (pharmacology)|glyceryl trinitrate]]), and [[loop diuretic]]s, such as [[furosemide]] or [[bumetanide]], is the mainstay of therapy. These improve both preload and afterload, and aid in improving cardiac function.

There are no causal therapies for direct tissue damage; removal of the causes (e.g. treating an infection) is the most important measure.

Sometimes the development of pulmonary edema will be referred to as '''flash pulmonary edema''' (FPE). This referes to the rapid onset of [[pulmonary edema]].  It is most often precipitated by [[acute myocardial infarction]] or [[mitral regurgitation]], but can be caused by aortic regurgitation, heart failure, or almost any cause of elevated left ventricular filling pressures. 

Treatment of FPE should be directed  at the underlying cause, but the mainstays are ensuring adequate oxygenation, diuresis, and decrease of pulmonary circulation pressures.

Reoccurrence of FPE is thought to be associated with [[hypertension]]<ref>Kramer K, Kirkman P, Kitzman D, Little WC. Flash pulmonary edema: association with hypertension and reoccurrence despite coronary revascularization. Am Heart J. 2000 Sep;140(3):451-5. PMID 10966547.</ref> and may signify [[renal artery stenosis]].<ref>Pickering TG, Herman L, Devereux RB, Sotelo JE, James GD, Sos TA, Silane MF, Laragh JH. Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by angioplasty or surgical revascularisation. ''Lancet'' 1988;2(8610):551-2. PMID 2900930.</ref> Prevention of reoccurrence is based on managing hypertension, coronary artery disease, renovascular hypertension, and heart failure.

Focus is initially on maintaining adequate oxygenation. This may happen with high-flow oxygen, noninvasive ventilation (either [[continuous positive airway pressure]] (CPAP) or variable positive airway pressure (VPAP)<ref>Masip J, Roque M, Sanchez B, Fernandez R, Subirana M, Exposito JA. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. ''JAMA'' 2005;294:3124-30. PMID 16380593.</ref><ref>Peter JV, Moran JL, Phillips-Hughes J, Graham P, Bersten AD. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. ''Lancet'' 2006;367(9517):1155-63. PMID 16616558.</ref>) or [[mechanical ventilation]] in extreme cases.

==Pathology and Case Report==

===Clinical Summary===

A 69-year-old male with well-controlled Type I [[diabetes mellitus]] (insulin-dependent) presented with upper abdominal and lower [[chest pain]] of four hours duration and accompanied by [[shortness of breath]] and [[diaphoresis]]. 

An [[electrocardiogram]] revealed multiple [[premature ventricular contraction]]s (PVCs). 

The hospital course was characterized by recurrent [[pulmonary edema]] and [[oliguria]]. 

The terminal event was [[cardiac arrest]].

===Autopsy Study===

Significant findings at postmortem examination were old and recent [[myocardial infarction]]s and evidence of [[congestive heart failure]]. 

The right and left lungs weighed 950 grams and 750 grams, respectively, and were reddish-brown. 

===Histopathological Findings===
[http://www.peir.net Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]

<div align="left">
<gallery heights="125" widths="125">
Image:Pulmonary edema case 1.1.jpg|This is a gross photograph of lungs that are distended and red. The reddish coloration of the tissue is due to congestion. Some normal pink lung tissue is seen at the edges of the lungs (arrows).
Image:Pulmonary edema case 1.2.jpg|This is a gross photograph of lung demonstrating acute pulmonary congestion and edema. A frothy exudate fills the bronchus (arrow).
Image:Pulmonary edema case 1.3.jpg|This gross photograph demonstrates the frothy exudate that is being extruded from the lung tissue.
</gallery>
</div>


<div align="left">
<gallery heights="125" widths="125">
Image:Pulmonary edema case 1.4.jpg|This is a low-power photomicrograph of lung from this case. The lung section has a pale-red color indicating proteinaceous material within the lung.
Image:Pulmonary edema case 1.5.jpg|This is a higher-power photomicrograph of lung. The edema fluid within the alveoli is visible at this higher magnification (arrows). The thickened pleura (1) is on the left.
</gallery>
</div>


<div align="left">
<gallery heights="125" widths="125">
Image:Pulmonary edema case 1.6.jpg|This is a higher-power photomicrograph showing edema-filled alveoli in the right portion of this section (arrows).
Image:Pulmonary edema case 1.7.jpg|This high-power photomicrograph illustrates the edema fluid within the alveoli (1) and the congestion (RBCs) in the alveolar capillaries (arrows).
</gallery>
</div>

==References==
{{reflist|2}}

==See also==
*[[High Altitude Pulmonary Edema]]
*[[Myocardial infarction]]

==External links==
*[http://patients.uptodate.com/topic.asp?file=hrt_fail/2458 Flash pulmonary edema] - UpToDate.com
*[http://heartdisease.about.com/od/livingwithheartfailure/a/diastolichf_2.htm Diastolic dysfunction] - heartdisease.about.com

{{Respiratory pathology}}
{{SIB}}

[[bs:Akutni edem pluća]]
[[de:Höhenlungenödem]]
[[es:Edema agudo de pulmón]]
[[ko:폐부종]]
[[it:Edema polmonare acuto]]
[[he:בצקת ריאות]]
[[nl:Longoedeem]]
[[new:पल्मोनरी इडिमा]]
[[ja:肺水腫]]
[[pt:Edema pulmonar]]
[[sr:Акутни едем плућа]]
[[fi:Keuhkoödeema]]
[[sv:Lungödem]]
[[pl:Obrzęk płuc]]
[[tr:Akciğer ödemi]]
[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Mountaineering]]
[[Category:Cardiology]]
[[Category:Physical Examination]]
[[Category:DiseaseState]]
[[Category:Signs and symptoms]]



{{WikiDoc Help Menu}}
{{WikiDoc Sources}}