1. ACUTE PULMONARY EDEMA

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

3. TYPES
Possible Cardiogenic Possible Non Cardiogenic

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

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

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

7. 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.

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

9. 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

10. RADIOLOGICAL SIGNS KERLEY A & B LINES

11. RADIOLOGICAL SIGNS
BAT WING SIGN

12. CT SCAN

13. COMET TAILS

14. ABG EARLY STAGES Hypoxemia Hypocapnia LATE STAGES Hypercapnia
Respiratory acidosis

15. ECG
LAH / LVH
Arrhythmias
AMI
Ischemic changes
Metabolic derangements

16. 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.

17. CENTRAL VENOUS CATHETER
CVP measurement
Administration of inotropes

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

19. 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

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

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

22. 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)

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

24. 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

25. 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

26. DOPAMINE
Indicated if SBP< 100mmHg
Increase myocardial oxygen demand

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

28. 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

29. 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

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

31. COMPLICATIONS
Hypotension
Pneumothorax
Corneal Drying

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

33. 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 %