STUDENTS NAME: - EMAD AL-HOLAIMI - MOHAMMED AL-ASIRI

Supervisor: Dr.Mohammed Sulaiman

OBJECTIVES:
- Definition of Pulmonary Edema
- Causes of Pulmonary Edema

- Sign & symptoms of Pulmonary Edema

- Pathophysiology of Pulmonary Edema

- Management of Pulmonary Edema

DEFENITION

Pulmonary edema is fluid accumulation in the lungs 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 a direct injury to the lung parenchyma ("noncardiogenic pulmonary edema").

CAUSES
A.

Cardiogenic
Severe Severe CHF Hypertension

heart attack with left ventricular failure

arrhythmias (tachycardia/ bradycardia)

B. o

Non-cardiogenic May occur after upper airway obstruction, intravenous fluid overload, neurogenic causes (seizures, head trauma, strangulation, electrocution).

Alveolar
Inhalation of toxic gases Pulmonary contusion, i.e., high-energy trauma Aspiration, e.g., gastric fluid or in case of drowning Multiple blood transfusions Infection

Other/unknown

Multitrauma, e.g., severe car accident Neurogenic, e.g., subarachnoid hemorrhage Certain types of medication

Upper airway obstruction, i.e. negative pressure pulmonary edema Arteriovenous malformation

SIGN & SYMPTOMS

Difficulty, Shortness of breathing Coughing up blood Excessive sweating

Anxiety
Pale skin

Wheezing
Cyanosis
(bluish discoloration of the skin due to poor blood circulation , lack of O2)

CONT.

A classic sign of pulmonary edema is the production of pink frothy sputum. If left untreated, it can lead to coma and even death, in general, due to its main complication of hypoxia. Other symptoms:
Paroxysmal nocturnal dyspnea (episodes of severe sudden breathlessness at night). Orthopnea (inability breathlessness). to lie down flat due to

PATHOPHYSIOLOGY

left-sided congestive heart failure left ventricle can't eject blood increase pulmonary vein pressure Fluid accumulates initially in the basal regions of the lower lobes because hydrostatic pressure is greater in these sites . Histologically, the alveolar capillaries are engorged, and an intra-alveolar granular pink precipitate is seen. Alveolar microhemorrhages may be present.

CONT.
MICROVASCULAR
INJURY (INCREASE IN CAPILLARY PERMEABILITY)

6 PHASES

1- Injury reduce normal blood flow to the lungs platelets aggregate and release histamine (H), serotonin (S), and bradykinin (B).

2those substance - especially histamine - inflame and damage the alveolocapillary membrane, increase capillary permeability fluids shift into interstitial space.

CONT.

3capillary permeability increase proteins and fluids leak out increase interstitial osmotic pressure and causing pulmonary edema

4- decrease blood flow and fluids in the alveoli damage surfactant alveoli collapse, impeding gas exchange and decrease lung compliance.

CONT.

5- O2 cant cross the alveolocapillary membrane, but CO2 can and is lost with every exhalation O2 & CO2 level decrease in blood.

6- pulmonary edema worsens, inflamation leads to fibrosis, and gas exchange is further impeded.

MANAGMENT

TREATMENT OF PULMONARY EDEMA,

INTRODUCTION

It

Is an Acute Life-Threatening Condition therefore Therapeutic Should be Applied Immediately

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TREATMENT OF PULMONARY EDEMA, INTRODUCTION

CONT.

Pulmonary edema is of different types :

1) Cardiogenic pulmonary edema : Due to left ventricular failure 2) Non cardiogenic pulmonary edema : Due to increased permeiability secondary to
sepsis
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TREATMENT OF PULMONARY EDEMA, INTRODUCTION

CONT.

Treatment of pulmonary edema depends upon the specific etiology BUT Given the fact that this condition is very serious then : Number of measures must be applied immediately to support : 1) The circulation 2) Gas exchange 3) Lung mechanics
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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

1] Support of Oxygenation and Ventilation for a patient with acute cardiogenic pulmonary edema generally have an identifiable cause of acute left venticular failure Such as A) Arrhythmia B) Ischemia/ infarction C) Myocardial decompensation

These can be treated rapidly improvement in Gas exchange

with
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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

1] Oxygen therapy :
Support

of oxygenation is essential to ensure a dequate oxygen delivery to the peripheral tissues including the heart . Oxygen is given by mask and start with high concentration to keep the Oxygen saturation above 90 %

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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

2]

Reduction of Preload :

For

most cases of pulmonary edema, the quantity of extravascular lung water is related to the intravascular volume status

How To Reduce The Preload On The Heart?

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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

A) Diuretics : The loop diuretics is preferred (Why?) Examples of loop diuretics:
1) Frusemide 2) Bumetanide 3) Torsemide

N.B The ascending loop of Henle has active reabsorbtion of more than 35% of the filtered Na

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FRUSEMIDE

PHARMACOLOGIC CATEGORY: Diuretic, Loop DOSING: ADULTS I.M., I.V.: 20-40 mg/dose, may be repeated in 1-2 hours as needed

USE Management of pulmonary edema associated with congestive heart failure

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FRUSEMIDE CONT.

Hemodynamic effects By reducing intravascular volume, diuresis will eventually lower central venous and pulmonary capillary wedge pressures.

Adverse effects : a. Hyperuricemia b. Acute hypovolemia c. potassium depletion e. hypomagnesemia

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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

B) Vasodilator therapy : Patients with acute cardiogenic pulmonary edema are often treated with vasodilators in an attempt to reduce preload and pulmonary capillary wedge pressure
In

the absence of symptomatic hypotension, intravenous, Nitroprusside may be considered as an addition to diuretic therapy for rapid improvement of congestive symptoms in patients admitted with Acute cardiogenic pulmonary edema 23

TREATMENT OF ACUTE PULMONARY EDEMA

CONT.

B) Nitrates : are the most commonly used vasodilators.They reduce LV filling pressure primarily via venodilation . Options for nitrate therapy include the following: 1) Nitrglycerin ( short acting ) An initial dose of 5-10 g/min of intravenous nitroglycerin is commonly used Or Sublingual nitroglycerin .4 mg every 5 minutes 2) Isosorbide dinitrate ( long acting ) It has longer half-life compared to intravenous nitroglycerin

Both drugs act predominantly as venodilator and coronary vasodilator as well They are rapid in onset and effective We need to monitor the blood pressure .

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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

Angiotensin-Converting Enzyme Inhibitors: These drugs reduce both the afterload as well as the preload. They work by inhibiting angiotensin II production which is a potent vasoconstrictor and this leads to vasodilatation example : Captopril
4]

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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

5] Digitalis Glycosides : It has positive inotropic action ..(rarely used nowadays) It is useful for control of ventricular rate in patient with rapid atrial fibrillation .

The digitalis glycosides show only a small Difference betwwen a therapeutics effective Dose and dose that are toxic or even fatal So .. These drugs have a low therapeutics index
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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

Arrhythmia management Both supraventricular and ventricular arrhythmias can occur in association with pulmonary edema. Atrial fibrillation Atrial fibrillation (AF) is a common arrhythmia, particularly in patients with underlying heart disease. Among patients with both HF and AF, there are several possible relationships : Acute HF can precipitate AF due to increases in left atrial pressure and wall stress . AF can cause acute HF, particularly if the ventricular response is rapid

6]

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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

If atrial fbrilation is the cause for the pulmonary edema or if the ventricular rate is fast, then a drug to control the rate is recommonded :

1)short-acting IV formulations of such drugs (eg, Esmolol or Diltiazem) are often used. 2) Digoxin is also potentially useful in this setting.

3) Amiodarone can be considered.

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TREATMENT OF ACUTE PULMONARY EDEMA CONT.

8] Sodium and Water Restriction :

Dietary sodium restriction is an important component of therapy to restore euvolemia

The

AHA guidelines on ADHF recommend a low sodium diet (2 g daily) The AHA guidelines recommend fluid restriction (<2 L/day)
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RESOURCES

Harrison's Principles of Internal Medicine 17th ed. Katzungs Basic and Clinical Pharmacology, 10th ed. Lippincott pharmacology 3rd ed.

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ANY QUESTIONS ?

THANK YOU !!