Sandbox:farnaz

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farnaz Khalighinejad, MD [2]

Overview

This is my sandbox.

Image reference

Pulmonary edema
Source: Wikimedia commons

Type 1:

Pulmonary edema

Cardiogenic

Non-cardiogenic

LV failure

Dysrthmia

LV hypertrophy and cardiomyopathy

Volume Overload

MI

LV outflow obstruction

Direct injury to lung

Hematogenous injury to lung

Lung injury plus elevated hydrostatic pressure

Chest trauma,pulmonary contusion

Aspiration

Smoke inhalation

Pneumonia

Oxygen toxicity

Pulmonary embolism,reperfusion

High altitude pulmonary edema

Neurogenic pulmonary edema

Reexpansion pulmonary edema

Sepsis

Pancreatitis

Nonthoracic trauma

Multiple transfusions

Intravenous drug use. e.g. heroin

• Direct injury to lung:
  • Pulmonary contusion
  • Aspiration
  • Smoke inhalation
  • Pneumonia
  • Oxygen toxicity
  • Pulmonary embolism,reperfusion
• Hematogenous injury to lung:
  • Sepsis
  • Pancreatitis
  • Nonthoracic trauma
  • Multiple transfusions
  • Intravenous drug use
  • Cardiopulmonary bypass
• Lung injury plus elevated hydrostatic pressure:
  • High altitude pulmonary edema
  • Neurogenic pulmonary edema
  • Reexpansion pulmonary edema

96 patients (174 eyes, 70% females) were included with a mean age at presentation of 30 years

Pulmonary edema treatment based on classification

Cardiogenic pulmonary edema

Noncardiogenic pulmonary edema

stabilize patient

Cause	Symptom	Diagnosis	Treatment
1
2
3

References

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [4]

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell);

Organ system			Diseases	Clinical manifestations											Diagnosis					Other features
				Symptoms						Physical exam
				Loss of consciousness	Agitation	Weight loss	Fever	Chest pain	Cough	Cyanosis	Clubbing	JVD	Peripheral edema	Auscultation	CBC	ABG	Imaging	Spirometry	Gold standard
			Pulmonary edema	+/-	+	-	+	+	+	+	+	+	+	Basal crackle	Normal	Respiratory alkalosis	Bat wing pattern, air bronchograms	↓Vt, ↑RV	Cardiac Catheterization	Tachypnea
Acute Dyspnea	Respiratory system	Chest and Pleura, Lower airway	Bronchiolitis	-	-	-	+	+/-	+	-	-	-	-	Wheeze and Crackles	↑WBC	Normal	Bronchovascular markings	↓Vt	Clinical assessment	Respiratory syncytial virus (RSV)
			COPD exacerbation	-	+	-	+	+	+	+	+/-	+/-	+/-	Wheeze, Rhonchi, and Crackles	↑WBC, ↑RBC	Respiratory alkalosis	Hyperexpansion	↓ FEV1/FVC	Clinical assessment	Acute exacerbations of chronic bronchitis (AECB)
			Lung carcinoma	-	-	+	-	-	+	+	+	-	-	Wheeze and Crackles	Normal	Normal	Mass lesion, hilar lymphadenopathy	↓Vt, ↑RV	Bronchoscopy	Paraneoplastic syndromes, such as SIADH and lambert-Eaton
			Pneumonia	-	-	-	+	+	+	-	-	-	-	Wheeze, Rhonchi, and Crackles	↑WBC, neutrophilia	Normal	Lobar consolidation	Normal	Chest X-ray and CT Scan	productive cough
Chronic Dyspnea	Respiratory system	Chest and Pleura, Lower airway	Bronchiectasis	-	-	-	+	+	+	+	+	-	-	Rhonchi, Wheezing, Crackles	↑WBC, neutrophilia	↓O2, ↑CO2	Tram-track opacities	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Chronic productive cough
			Interstitial lung disease	-	-	-	-	+	+	+	+	-	-	Rhonchi, Wheezing, Crackles	Normal	↓O2, ↑CO2	Peripheral pulmonary infiltrative opacification	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Pneumoconiosis
			Sarcoidosis	-	-	+/-	-	+/-	+	+	-	-	-	Crackles	Normal	↓O2, ↑CO2	Hilar adenopathy	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Hypercalcemia, high ACE
			Alveolitis	-	-	-	+	+	+	-	-	-	-	Basal crackle	↑WBC, neutrophilia	Normal	Basal reticulonodular opacification	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Dry cough
			Cystic fibrosis	-	-	+	+	-	+/-	+	+	-	-	Rhonchi, Wheezing, Crackles	Normal	Metabolic alkalosis	Thick-walled bronchiectasis	↓ FEF75%/FVC	Sweat test	Absent vas deferens
			Tuberculosis	-	-	+	+	+	+	+/-	-	-	-	Rhonchi, Wheezing, Crackles	↑WBC	↓O2, ↑CO2	Patchy consolidation or poorly defined linear and nodular opacities	Restrictive, obstructive, or mixed	IFN-γ release assay (IGRA) Acid-fast staining	Night sweat
	Autoimmune		Wegener's granulomatosis	-	-	+/-	-	-	+	-	-	-	-	Wheezing, Crackles	↓ RBC	↓O2, ↑CO2	Cavitate nodules, ground-glass opacity	↓ FEV1/FVC	Biopsy demonstrating a granulomatous vasculitis	Chronic rhinosinusitis

Prevention of pulmonary edema

Non-cardiogenic pulmonary edema

Cardiogenic pulmonary edema

❑ Encourage healthy lifestyle and exercise ❑ Precautions for pulmonary edema associated with high altitude ❑ ❑ (I-A) ❑ Control obesity (I-C) ❑ (I-C) ❑ Avoid tobacco (I-C) ❑ ❑

❑ Encourage healthy lifestyle and exercise ❑ Treat hypertension (I-A) ❑ Treat dyslipidemia (I-A) ❑ Control obesity (I-C) ❑ Treat DM (I-C) ❑ Avoid tobacco (I-C) ❑ Avoid cardiotoxic agents (I-C)

Consider additional measures in selected patients: ❑ Administer ACE-I if history of MI or ACS and reduced EF to prevent symptoms and reduce mortality (I-A), in all decreased EF to prevent symptoms (I-A) ❑ Administer beta-blockers if history of MI or ACS and reduced EF to reduce mortality (I-B), in all reduced EF to prevent symptoms (I-C) ❑ Administer statins if history of MI or ACS to prevent symptoms (I-A) ❑ Consider ICD placement to prevent sudden death if asymptomatic ischemic cardiomyopathy, > 40 days post-MI, LVEF ≤30%, on adequate medical therapy, and good 1 year survival

A01

B01

B02

D01

D02

D03

D04

D05

Pulmonary edema treatment based on classification

Cardiogenic pulmonary edema

Noncardiogenic pulmonary edema

❑ First step is to stabilize the patient by following the ABCs of resuscitation, that is, airway, breathing, and circulation ❑ Any associated arrhythmia or myocardial infarction should be treated appropriately ❑Following drugs are used: ❑ ACE-I or ARB ❑Beta blockers ❑ Bisoprolol  :❑Carvedilol :❑Sustained release metoprolol succinate PLUS ❑Loop diuretics ❑ Starting dose: :❑ Furosemide 20 to 40 mg, OR :❑ Torsemide 10 to 20 mg, OR :❑ Bumetanide 0.5 to 1 mg ❑ Monitor volume status and adjust dose ❑ No response: double oral diuretics dose rather than administer BID ❑No or minimal response despite maximal diuretic dose then administer anotherdiuretics BID or TID PLUS ❑Aldosterone antagonist ❑Vasopressin antagonists: ❑ Conivaptan ❑Tolvaptan ❑ Type III phosphodiesterease inhibitors ❑Milrinone and enoximone

❑Treatment of the underlying cause is very important ❑ If the cause of pulmonary edema is overdose of opioid overdose :❑ Naloxone is used for the reversal of symptoms ❑ Salicylate toxicity :❑ Sodium bicarbonate is used for the treatment ❑ High altitude pulmonary edema treatment:  :❑ Oxygen therapy is the first line therapy  :❑ Nifedipine :❑Tadalafil and Sildenafil ❑Anticoagulants are used for the treatment of pulmonary edema due to pulmonary embolism ❑Antibiotics are used to treat underlying infections