What is pulmonary edema?
Pulmonary edema is a severe pathological condition associated with a massive release of a transudate of a non-inflammatory nature from the capillaries to the interstitium of the lungs, then to the alveoli. The process leads to a decrease in the functions of the alveoli and impaired gas exchange, hypoxia develops. The gas composition of the blood changes significantly, increasing the concentration of carbon dioxide. Along with hypoxia, severe depression of the central nervous system functions occurs. Exceeding the normal (physiological) level of interstitial fluid leads to edema.
In the composition of the interstitium is: lymphatic vessels, connective tissue elements, intercellular fluid, blood vessels. The entire system is covered with visceral pleura. Branched hollow tubes and tubes are a complex that makes up the lungs. The whole complex is immersed in the interstitium. The interstitium is formed by plasma leaving the blood vessels. Then the plasma is absorbed back into the lymphatic vessels flowing into the vena cava. According to this mechanism, the extracellular fluid delivers oxygen and necessary nutrients to the cells, removes metabolic products.
Violation of the number and outflow of intercellular fluid leads to pulmonary edema:
when an increase in hydrostatic pressure in the blood vessels of the lungs caused an increase in interstitial fluid, hydrostatic edema occurs;
the increase was due to excessive filtration of the plasma (for example: with the activity of inflammatory mediators) membrane edema occurs.
Depending on the rate of transition of the interstitial stage of edema to alveolar, the patient’s condition is assessed. In the case of chronic diseases, edema develops more smoothly, more often at night. Such edema is well stopped by drugs. Edema associated with mitral valve defects, myocardial infarction, and damage to the pulmonary parenchyma increases rapidly. The condition is deteriorating rapidly. Edema in acute form leaves very little time to respond.
Prognosis of the disease
The prognosis of pulmonary edema is unfavorable. It depends on the causes of the actual swelling. If the swelling is non-cardiogenic, it is well treatable. Cardiogenic edema is difficult to arrest. After prolonged treatment after cardiogenic edema, the survival rate during the year is 50%. In the form of lightning – to save a person often fails.
For toxic edema, the prognosis is very serious. Favorable prognosis when taking large doses of diuretics. It depends on the individual reaction of the body.
The picture of any type of pulmonary edema is bright. Therefore, the diagnosis is simple. For adequate therapy, it is necessary to identify the causes of the edema. Symptoms depend on the form of edema. The lightning form is characterized by rapidly increasing suffocation and respiratory arrest. The acute form has more pronounced symptoms, in contrast to the subacute and prolonged.
Symptoms of pulmonary edema
The main symptoms of pulmonary edema include:
cyanosis (face and mucous membranes acquire a bluish tint);
chest tightness, pain of pressing nature;
rattling rattles are heard;
with increasing cough – frothy pink sputum;
with the deterioration of the sputum from the nose;
a person is frightened, consciousness may be confused;
sweating, sweat cold and clammy;
increased heart rate up to 200 beats per minute. It can easily go into life-threatening bradycardia;
drop or jumps in blood pressure.
Pulmonary edema itself is a disease that does not occur on its own. Many pathologies can lead to edema, sometimes not at all associated with diseases of the bronchopulmonary and other systems.
Causes of pulmonary edema
The causes of pulmonary edema include:
Sepsis. It is usually the penetration of exogenous or endogenous toxins into the bloodstream;
Overdose of some (NSAIDs, cytostatics) drugs;
Radiation damage to the lungs;
Overdose of narcotic substances;
Myocardial infarction, heart disease, ischemia, hypertension, any heart disease in the stage of decompensation;
Congestions in the right circle of blood circulation that occur during bronchial asthma, emphysema and other pulmonary diseases;
A sharp or chronic decrease in protein in the blood. Hypoalbuminemia occurs in liver cirrhosis, nephrotic syndrome and other renal pathologies;
Infusions in large volumes without forced diuresis;
Toxic gas poisoning;
Shock for serious injuries;
Being at high altitude;
Types of pulmonary edema
There are two types of pulmonary edema: cardiogenic and non-cardiogenic. There is also a 3rd group of pulmonary edema (refers to non-cardiogenic) – toxic edema.
Cardiogenic swelling (heart swelling)
Cardiogenic edema is always caused by acute left ventricular failure, mandatory stagnation of blood in the lungs. Myocardial infarction, heart defects, angina, arterial hypertension, left ventricular failure – the main causes of cardiogenic edema. To associate pulmonary edema with chronic or acute heart failure, measure the capillary pressure of the lungs. In the case of cardiogenic edema, the pressure rises above 30 mm Hg. Art. Cardiogenic edema provokes transudation of fluid into the interstitial space, then into the alveoli. Attacks of interstitial edema are observed at night (paroxysmal shortness of breath). The patient does not have enough air. Auscultation determines hard breathing. Breath increased as you exhale. Asphyxiation is the main symptom of alveolar edema.
The following symptoms are characteristic of cardiogenic edema:
inspiratory dyspnea. A sedentary position is characteristic of the patient; in the prone position, shortness of breath increases;
hyperhydration of tissues (edema);
dry whistling, turning into moist gurgling rales;
separation of pink frothy sputum;
unstable blood pressure. It is difficult to reduce to normal. Lowering the rate can lead to bradycardia and death;
severe pain in the chest or in the chest;
On the electrocardiogram, hypertrophy of the left atrium and the ventricle is read, sometimes blockade of the left leg of the bundle of His.
Hemodynamic conditions of cardiogenic edema
violation of left ventricular systole;
The leading cause of cardiogenic edema is left ventricular dysfunction.
Cardiogenic edema should be differentiated from non-cardiogenic edema. In the case of non-cardiogenic edema, changes in the cardiogram are less pronounced. Cardiogenic edema proceeds more quickly. Time for emergency care is given less than with a different form of edema. Fatal outcome most often with cardiogenic edema.
Toxic pulmonary edema
Toxic edema has certain specific differentiating features. There is a period here when the edema itself is not yet present, there is only the body’s reflex reactions to irritation. The burn of the lung tissue, the burn of the respiratory tract cause reflex spasm. This is a combination of symptoms of lesions of the respiratory organs and resorptive effects of toxic substances (poisons). Toxic edema can develop regardless of the dose of drugs that caused it.
Drugs that can cause lung edema:
nonsteroidal anti-inflammatory drugs.
Risk factors for the occurrence of toxic edema are old age, long-term smoking.
It has 2 forms developed and abortive. There is a so-called dumb swelling. It can be detected by radiological examination of the lungs. A certain clinical picture of such edema is practically absent.
It is characterized by periodicity. Has 4 periods:
Reflex disorders. It is characterized by symptoms of irritation of the mucous membranes: lacrimation, coughing, shortness of breath. The period is dangerous with respiratory and cardiac arrest;
The hidden period subsides irritations. May last 4-24 hours. Characterized by clinical well-being. A thorough examination can show signs of impending edema: bradycardia, pulmonary emphysema;
Directly pulmonary edema. The flow is sometimes slow, reaching 24 hours. Most often, the symptoms increase in 4-6 hours. In this period, the temperature rises, there is a neutrophilic leukocytosis in the blood formula, there is a danger of collapse. A developed form of toxic edema has a fourth period of complete edema. The completed period has blue hypoxemia. Cyanosis of the skin and mucous membranes. The completed period increases the respiratory rate up to 50-60 times per minute. Vibrant breath is heard at a distance, sputum mixed with blood. Increases blood clotting. Gas acidosis develops. Gray hypoxemia is characterized by a more severe course. Join vascular complications. The skin gets a pale grayish tint. The limbs are cold. Filamentous pulse and drop to critical values of blood pressure. This state contributes to physical activity or improper transportation of the patient;
Complications. When leaving the period of direct pulmonary edema, there is a risk of secondary edema. It is associated with left ventricular failure. Pneumonia, pneumosclerosis, emphysema – frequent complications caused by drugs, toxic edema. At the end of the 3rd week, “secondary” edema may occur on the background of acute heart failure. Rarely occurs exacerbation of latent tuberculosis and other chronic diseases. Depression, drowsiness, asthenia.
With rapid and effective therapy, a period of reverse development of edema begins. It does not belong to the main periods of toxic edema. It all depends on the quality of assistance provided. Cough and shortness of breath decrease, cyanosis decreases, wheezing in the lungs disappears. On X-rays, the disappearance of large, then small foci is noticeable. The picture of peripheral blood is normalized. The period of recovery from toxic edema may be several weeks.
In rare cases, toxic edema can be caused by taking tocolytics. The catalyst for edema can be: large amounts of injected fluid, recent treatment with glucocorticoids, multiple pregnancy, anemia, unstable hemodynamics in women.
Clinical manifestations of the disease:
The key symptom is respiratory failure;
Severe chest pain;
Cyanosis of the skin and mucous membranes;
Hypotension in combination with tachycardia.
Toxic edema differs from cardiogenic edema by a protracted course and the content of a small amount of protein in a liquid. The size of the heart does not change (rarely change). Venous pressure is often within normal limits.
Diagnosis of toxic edema is not difficult. The exception is bronchorea with FOS poisoning.
Non-cardiogenic pulmonary edema
Occurs due to increased vascular permeability and high fluid filtration through the wall of the pulmonary capillaries. With a large amount of liquid, the work of the vessels deteriorates. The fluid begins to fill the alveoli and gas exchange is disturbed.
Causes of non-cardiogenic edema:
renal artery stenosis;
massive renal failure, hyperalbuminemia;
pneumothorax may cause unilateral non-cardiogenic pulmonary edema;
severe asthma attack;
inflammatory diseases of the lungs;
aspiration of gastric contents;
shock, especially in sepsis, aspiration, and pancreatic necrosis;
inhalation of toxic substances;
large drug transfusions;
in elderly patients who take acetylsalicylic acid for a long time;
To clearly distinguish between edemas, the following measures should be taken:
study the history of the patient;
apply methods of direct measurement of central hemodynamics;
assess the area affected by myocardial ischemia (enzyme analyzes, ECG).
For the differentiation of non-cardiogenic edema, the main indicator will be the measurement of the jamming pressure. Normal cardiac output, positive wedging pressure results indicate the non-cardiogenic nature of the edema.
Effects of pulmonary edema
When the swelling is stopped, it is too early to finish the treatment. After an extremely severe state of pulmonary edema, serious complications often occur:
the accession of a secondary infection. Most often pneumonia develops. Against the background of reduced immunity, even bronchitis can lead to adverse complications. Pneumonia against pulmonary edema is difficult to treat;
hypoxia, characteristic of pulmonary edema, affects vital organs. The most serious consequences can affect the brain and the cardiovascular system – the effects of edema may be irreversible. Disruption of cerebral circulation, cardiosclerosis, heart failure without a powerful pharmacological support are fatal;
ischemic damage of many organs and body systems;
pneumofibrosis, segmental atelectases.
Emergency care for pulmonary edema
Required for each patient with signs of pulmonary edema. Highlights of emergency care:
the patient must be given a half-sitting position;
aspiration (removal) of foam from the upper respiratory tract. Aspiration is performed by inhalation of oxygen through 33% ethanol;
urgent oxygen inhalation (oxygen therapy);
elimination of acute pain syndrome with neuroleptics;
recovery of heart rhythm;
electrolyte balance correction;
normalization of acid-base balance;
normalization of hydrostatic pressure in the pulmonary circulation. Used narcotic analgesics Omnopon, Promedol. They inhibit the respiratory center, relieve tachycardia, reduce the flow of venous blood, reduce blood pressure, reduce anxiety and fear of death;
vasodilators (aerosol Nitromint). Means reduce vascular tone, intrathoracic blood volume. Nitroglycerin preparations facilitate the outflow of blood from the lungs, acting on peripheral vascular resistance;
imposing of venous turnstiles on the lower extremities. The procedure is necessary to reduce the CSC – the old effective method. Now for dehydration of the lung parenchyma use 40 mg of lasix intravenously. The action of furosemide (lasix) develops within a few minutes, lasts up to 3 hours. The drug is able to in a short period of time to withdraw 2 liters of urine. The reduced plasma volume with increased colloid osmotic pressure promotes the transfer of edematous fluid into the bloodstream. Filtration pressure decreases. With low blood pressure, diuretics can be used only after normalization;
the appointment of diuretics for the dehydration of the lungs (Lasix 80 mg intravenously);
the appointment of cardiac glycosides to increase myocardial contractility;
Major complications after emergency care
These complications include:
development of fulminant edema;
intensive foam production can cause airway obstruction;
angiotic pain. This pain is characterized by unbearable pain, the patient may experience a painful shock, worsening the prognosis;
inability to stabilize blood pressure. Often, pulmonary edema occurs on the background of low and high blood pressure, which can alternate within a large amplitude. The vessels will not be able to withstand such a load for a long time and the patient’s condition worsens;
increased pulmonary edema due to high blood pressure.
Treatment of pulmonary edema
It comes down to one thing – remove swelling as soon as possible. Then, after intensive therapy of the pulmonary edema, agents are prescribed to treat the disease that provoked the edema.
So, means to relieve edema and subsequent therapy:
Morphine hydrochloride. A vital drug for the treatment of cardiogenic type and other edemas in case of hyperventilation. The introduction of morphine hydrochloride requires readiness to transfer the patient to controlled breathing;
Nitrate preparations in the infusion form (glycerol trinitrate, isosorbitol dinitrate) are used for any edema, excluding edema with hypovolemia during pulmonary thromboembolism;
The introduction of loop diuretics (Furosemide, Torasemide) in the first minutes of edema saves the lives of many patients;
In the case of cardiogenic pulmonary edema resulting from myocardial infarction, the introduction of tissue plasminogen activator is necessary;
For atrial fibrillation, Amiodarone is prescribed. Only with low efficiency of electropulse therapy. Often, against the background of even a small decrease in rhythm, the patient’s condition may deteriorate significantly. When prescribing amiodarone, dobutamine infusion is sometimes required to increase rhythm;
Corticosteroids are used only for non-cardiogenic edema. Dexamethasone is most commonly used. It is actively absorbed into the systemic circulation and adversely affects the immune system. Modern medicine now recommends the use of methylprednisolone. The period of its elimination is much less, side effects are less pronounced, the activity is higher than that of dexamethasone;
Dopamine is used for inotropic rhythm support in overdose of b-blockers;
Cardiac glycosides (digoxin) are necessary for chronic atrial fibrillation;
“Ketamine”, sodium thiopental are necessary for short-term anesthesia, for relieving pain syndrome;
Diazepam with ketamine is used for sedation;
When heroin edema of the lungs or iatrogenic complications prescribed muscle relaxants (naloxone);
In conditions of high-altitude pulmonary edema, “Nifedipine” is needed, it quickly lowers blood pressure;
At the inpatient stage of treatment, shock doses of antibiotics are prescribed to prevent the addition of infection. In the first place are drugs from the group of fluoroquinolones: “Tavanic”, “Tsifran”, levofloxacin;
To facilitate the withdrawal of accumulated fluid, large doses of ambroxol are prescribed;
Mandatory appointment of surfactant. It reduces tension in the alveoli, has a protective effect. Surfactant improves the absorption of oxygen by the lungs, reduces hypoxia;
Sedatives for pulmonary edema. In the treatment of patients with pulmonary edema, the normalization of the emotional background plays a leading role. Often by itself, severe stress can trigger swelling. The trigger mechanism of stress often causes pancreatic necrosis and myocardial infarction. Sedatives can, in combination with other drugs, normalize the content of catecholamines. Due to this, the spasm of the peripheral vessels is reduced, the blood flow is significantly reduced, the stress is relieved from the heart. The normal functioning of the heart allows to improve the outflow of blood from the small circle. The sedative effect of sedatives can relieve the vegetative-vascular manifestations of edema. With the help of sedatives, it is possible to reduce the filtration of tissue fluid through the alveolar-capillary membrane. Means that can affect the emotional background can reduce blood pressure, tachycardia, reduce shortness of breath, vegetative-vascular manifestations, reduce the intensity of metabolic processes – this facilitates the course of hypoxia. Apart from the solution of morphine – the first, most effective aid for pulmonary edema, 4 ml of droperidol 0.25% solution or Relanum 0, 5% – 2 ml is prescribed. Unlike morphine, these drugs are used in all types of pulmonary edema;
Ganglioblockers: “Arfonad”, pentamine, benzohexonium. Allow to quickly stop pulmonary edema with high blood pressure (from 180 mm
Pulmonary edema treatment algorithm
The treatment algorithm itself can be divided into 7 stages:
cardiac glycosides for cardiogenic edema and glucocorticoids for noncardiogenic;
after relief of edema – hospitalization for the treatment of the underlying disease.
For the relief of 80% of pulmonary edema, morphine hydrochloride, furosemide and nitroglycerin are sufficient.
Then begin therapy of the underlying disease:
in case of cirrhosis of the liver, hyperalbuminemia, a course of hepatoprotectors is prescribed: “Heptral”, with preparations of thioctic acid: “Thioctacid”, “Berlition”;
if the edema is caused by pancreatic necrosis, it is prescribed drugs that suppress the work of the pancreas Sandostatin, then stimulate the healing of the necrosis Timalin, Immunofan, along with powerful enzyme therapy – Creon;
complex therapy of myocardial infarction. B-blockers Concor, Metoprolol. And angiotensin-converting enzyme blockers Enalapril, antiplatelet agents Thrombotic;
for bronchopulmonary diseases, a course of antibiotics is needed. Preference is given to macrolides and fluoroquinolones, penicillins are currently ineffective. Ambroxol prescription drugs: Lasolvan, Ambrobene – they have not only expectorant effects, but also have anti-inflammatory properties. Mandatory appointment of immunomodulators. The state of the lungs after edema is unstable. Secondary infection can lead to death;
in the case of toxic edema, detoxification therapy is prescribed. Replenishment of fluid lost after diuretics, restoration of electrolyte balance is the main effect of salt mixtures. Drugs aimed at relieving symptoms of intoxication: Regidron, Enterosgel, Enterodez. For severe intoxication, antiemetic agents are used;
in severe asthma, glucocorticosteroids, mucolytics, expectorant drugs, bronchodilators are prescribed;
in case of toxic shock, antihistamines are prescribed: “Cetrin”, “Claritin”, in combination with corticosteroids;
pulmonary edema of any etiology requires the prescription of powerful antibiotics and effective antiviral (immunomodulatory) therapy. The newest destination fluoroquinolones plus Amixin, Cycloferon, Polyoxidonium. The prescription of antifungal agents is often required, since antibiotics promote their growth. Terbinafine, Fluconazole will help prevent superinfection;
To improve the quality of life, enzymes are prescribed: Wobenzym and immunomodulators: Polyoxidonium, Cycloferon.
The prognosis after suffering pulmonary edema is rarely favorable. For survival during the year must be monitored. Effective treatment of the underlying disease that causes pulmonary edema significantly improves the patient’s quality of life and prognosis.
Therapy of pulmonary edema primarily comes down to actually removing the edema itself. Inpatient therapy is aimed at treating the disease that provoked edema.
Education: The diploma in the specialty “Andrology” was obtained after passing residency at the Department of Endoscopic Urology of the Russian Academy of Medical Education at the Urology Center of the Central Clinical Hospital №1 of Russian Railways (2007). It was also completed graduate school by 2010.