1. Copyright © 2006 by Mosby, Inc. Slide 1 PART IV Pulmonary Vascular Diseases

2. Copyright © 2006 by Mosby, Inc. Slide 2 Chapter 19 Pulmonary Edema Figure 19-1. Pulmonary edema. Cross-sectional view of alveoli and alveolar duct in pulmonary edema. FWS, Frothy white secretions; IE, interstitial edema; RBC, red blood cell. Inset, Atelectasis, a common secondary anatomic alteration of the lungs. FWS IE RBC

3. Copyright © 2006 by Mosby, Inc. Slide 3 Anatomic Alterations of the Lungs  Interstitial edema, including fluid engorgement of the perivascular and peribronchial spaces and the alveolar wall interstitium  Alveolar flooding  Increased surface tension of pulmonary surfactant  Alveolar shrinkage and atelectasis  Frothy white (or pink) secretions throughout the tracheobronchial tree

4. Copyright © 2006 by Mosby, Inc. Slide 4 Etiology  Cardiogenic pulmonary edema  Congestive heart failure

5. Copyright © 2006 by Mosby, Inc. Slide 5 Etiology Movement of fluid in and out of the capillaries is expressed by Starling’s equation: J = K (Pc – Pi) – (  c –  i) where J is the net fluid movement out of the capillary, K is the capillary permeability factor, Pc and Pi are the hydrostatic pressures in the capillary and interstitial space, and  c and  i are the oncotic pressures in the capillary and interstitial space

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9. Copyright © 2006 by Mosby, Inc. Slide 9 Etiology Noncardiogenic pulmonary edema  Increased capillary permeability  Alveolar hypoxia  Acute respiratory distress syndrome  Inhalation of toxic agents  Pulmonary infections  Therapeutic radiation of the lungs  Head injury

10. Copyright © 2006 by Mosby, Inc. Slide 10 Etiology  Lymphatic insufficiency  Decreased intrapleural pressure  Decreased oncotic pressure  Overtransfusion  Uremia  Hypoproteinemia  Acute nephritis  Polyarteritis nodosa

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13. Copyright © 2006 by Mosby, Inc. Slide 13 Overview of the Cardiopulmonary Clinical Manifestations Associated with PULMONARY EDEMA The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Atelectasis (see Figure 9-7), Increased Alveolar-Capillary Membrane Thickness (see Figure 9-9) and, in severe cases, Excessive Bronchial Secretions (see Figure 9-11)—the major anatomic alterations of the lungs associated with pulmonary edema (see Figure 19-1)

14. Copyright © 2006 by Mosby, Inc. Slide 14 Figure 9-7. Atelectasis clinical scenario.

15. Copyright © 2006 by Mosby, Inc. Slide 15 Figure 9-9. Increased alveolar-capillary membrane thickness clinical scenario.

16. Copyright © 2006 by Mosby, Inc. Slide 16 Figure 9-11. Excessive bronchial secretions clinical scenario.

17. Copyright © 2006 by Mosby, Inc. Slide 17 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Increased heart rate, cardiac output, blood pressure

18. Copyright © 2006 by Mosby, Inc. Slide 18 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside  Cheyne-Stokes respiration  Paroxysmal nocturnal dyspnea (PND) and orthopnea  Cyanosis  Cough and sputum (frothy and pink)  Chest assessment findings  Increased tactile and vocal fremitus  Crackles, rhonchi, and wheezing

19. Copyright © 2006 by Mosby, Inc. Slide 19 Clinical Data Obtained from Laboratory Tests and Special Procedures

20. Copyright © 2006 by Mosby, Inc. Slide 20 Pulmonary Function Study: Expiratory Maneuver Findings FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or  FVC FEV T FEF 25%-75% FEF 200-1200  N or  N or  N PEFR MVV FEF 50% FEV 1% N N or  N N or 

21. Copyright © 2006 by Mosby, Inc. Slide 21 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC N or     VC IC ERV RV/TLC%    N V T RV FRC TLC N or     VC IC ERV RV/TLC%    N

22. Copyright © 2006 by Mosby, Inc. Slide 22 Arterial Blood Gases Mild to Moderate Pulmonary Edema  Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly)  pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

23. Copyright © 2006 by Mosby, Inc. Slide 23 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. Pa O 2 and Pa CO 2 trends during acute alveolar hyperventilation.

24. Copyright © 2006 by Mosby, Inc. Slide 24 Arterial Blood Gases Severe Pulmonary Edema  Acute ventilatory failure with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (slightly)  pH PaCO 2 HCO 3 - PaO 2    (slightly) 

25. Copyright © 2006 by Mosby, Inc. Slide 25 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Acute Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute ventilatory failure.

26. Copyright © 2006 by Mosby, Inc. Slide 26 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2   Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal Normal O 2 ER Sv O 2  

27. Copyright © 2006 by Mosby, Inc. Slide 27 Hemodynamic Indices (Cardiogenic Pulmonary Edema) CVP RAPPAPCWP   COSVSVICI     RVSWILVSWIPVRSVR     CVP RAPPAPCWP   COSVSVICI     RVSWILVSWIPVRSVR    

28. Copyright © 2006 by Mosby, Inc. Slide 28 Abnormal Laboratory Tests and Procedures  Serum potassium: low  Serum sodium: low  Hypokalemia and hyponatremia are often seen in patients with left-sided heart failure and may result from diuretic therapy or excessive fluid retention

29. Copyright © 2006 by Mosby, Inc. Slide 29 Radiologic Findings Chest radiograph  Fluffy opacities  Left ventricular hypertrophy  Kerley A and B lines  Pleural effusion

30. Copyright © 2006 by Mosby, Inc. Slide 30 Figure 19-2. Cardiomegaly (arrow) and pulmonary edema in congestive heart failure.

31. Copyright © 2006 by Mosby, Inc. Slide 31 General Management of Pulmonary Edema Respiratory care treatment protocols  Oxygen therapy protocol  Bronchopulmonary hygiene therapy protocol  Hyperinflation therapy protocol  Aerosolized medication protocol

32. Copyright © 2006 by Mosby, Inc. Slide 32 General Management of Pulmonary Edema Medications and procedures commonly prescribed by the physician  Positive inotropic agents  Afterload reduction agents  Morphine sulfate  Diuretic agents

33. Copyright © 2006 by Mosby, Inc. Slide 33 General Management of Pulmonary Edema Medications and procedures commonly prescribed by the physician  Albumin and mannitol  Alcohol (ethanol, ethyl alcohol)  Decreasing hydrostatic pressure  Positioning the patient in Fowler’s position  Rotating tourniquets (rarely used)  Phlebotomy (rarely used)

34. Copyright © 2006 by Mosby, Inc. Slide 34 Classroom Discussion Case Study: Pulmonary Edema