ACUTE PULMONARY EDEMA

DEFINATION Rapid accumulation fluid into the interstitial spaces, alveoli & bronchioles from the pulmonary capillaries, beyond the capacity of clearing system of the lungs

TYPES Possible Cardiogenic Possible Non Cardiogenic

CARDIOGENIC PULMONARY EDEMA CHF PERICARDIAL EFFUSION HYPERTENSIVE CRISIS FLUID OVERLOAD ACUTE MI ARRYTHMIAS

NON CARDIOGENIC CAUSES Smoke inhalation. Aspiration. Trauma. Neurogenic. Infection. Transfusion related. High altitude. Expansion. Narcotic overdose. Airway obstruction/ negative pressure.

AGGRAVATING CAUSES Myocardial Ischemia / Infract. Pneumonia. Arrhythmia. Pregnancy. Excessive salt in diet.

PATHOPHYSIOLOGY Imbalance of Hydrostatic forces( increased pulmonary capillary pressure, decreased plasma oncotic pressure, increased negative interstitial pressure). Damage to the alveolar-capillary barrier. lymphatic obstruction. Idiopathic or unknown mechanism.

SYMPTOMS Difficulty in breathing. Hemorrhagic frothy Cough. Orthopnea . Paroxysmal nocturnal dyspnea. Excessive sweating. Pale skin.

INVESTIGATIONS Other tests Lab studies Procedures Imaging studies ABG Pulseoxymetry ECG BNP / Pro BNP Procedures PCWP – Swan Ganz catheter Central venous catheter Lab studies CBC Serum electrolytes BUN / Creatinin Imaging studies Chest xray CT Scan chest USG Thorax

RADIOLOGICAL SIGNS KERLEY A & B LINES

RADIOLOGICAL SIGNS BAT WING SIGN

CT SCAN

COMET TAILS

ABG EARLY STAGES Hypoxemia Hypocapnia LATE STAGES Hypercapnia Respiratory acidosis

ECG LAH / LVH Arrhythmias AMI Ischemic changes Metabolic derangements

BNP To diagnose if Cardiogenic or non Cardiogenic origin. High negative predictive value. Cut off value is 100 pg/ml. 100–300 pg/mL Heart failure.

CENTRAL VENOUS CATHETER CVP measurement Administration of inotropes

GOALS Preload reduction: Nitroglycerin, Loop diuretics, Morphine sulfate After load reduction: ACE inhibitors, Nitroprusside, Inotropes

FURESEMIDE Reduces preload Vasodilatation Pulls the extra fluid out of the circulation Keeps fluid moving out of the kidney Effects seen within 5-15 minutes of administration

NITROGLYCERIN Relieves myocardial workload Dilates the arterial and venous systems Reduces preload to the already overworked ventricles Reduces blood pressure to reduce Afterload.

IV NITROGLYCERIN 5 mics / min initially Titrate upwards every 5 mins on monitoring BP Max upto 400 mics / min

MORPHINE Relieves myocardial workload Dilates venous and arterial Reduces preload and Afterload May cause hypotension 2-4mg over 1-2 minutes, every 5 minutes (usual max dose 10 mg)

NITROPRUSSIDE Preload and Afterload reduction High patency & rapid onset Avoid in case of AMI Prolonged use associated with thiocyanate toxicity

ACE INHIBITORS Enalapril 1.25 mg IV / Captopril 25 mg S/L Hemodynamic and subjective improvements within 10 mins Reduced afterload Slight reduction in preload

INOTROPES DOBUTAMINE Indicated if SBP> 100mmHg IV Positive inotropic effects with mild chronotropic effects It also induces mild peripheral vasodilation Combination with IV NTG is ideal for patients In general

DOPAMINE Indicated if SBP< 100mmHg Increase myocardial oxygen demand

NORADRENALINE Indicated if SBP< 60 mmHg Significantly increases afterload Generally reserved for patients with profound hypotension

NPPV (BiPAP / CPAP) INTIAL SETTINGS IPAP = Pressure support EPAP = PEEP Commonly IPAP set to 14cmH2O and EPAP to 6 cmH2O Response to pressure should determine future changes

ABSOLUTE CONTRAINDICATIONS Age < 8 Respiratory or Cardiac Arrest Agonal Respirations Severely depressed LOC Systolic Blood Pressure < 90 Pneumothorax Major Trauma, esp. head injury with increased ICP or significant chest trauma Facial Anomalies (e.g. burns, fractures) Vomiting

RELATIVE CONTRAINDICATIONS History of Pulmonary Fibrosis Decreased LOC Claustrophobia or unable to tolerate mask (after initial 1-2 minutes).

COMPLICATIONS Hypotension Pneumothorax Corneal Drying

INTUBATION & VENTILATION Airway – Not patent BiPAP - Not tolerating - Contraindication Premedication – Midazolam - Morphine or Fentanyl

BETTER MODE Paralyzed & Sedated PCV High peep RR – 10-12/min Insp time – 0.8 to 1 sec if needed 1:1 or 2:1 Spo2 – 100 %