1. Dyspnoea III – Pulmonary oedema
EMC SDMH 2015

2. Define the pulmonary oedema syndrome and understand differing aetiologies
Recognise predisposing and precipitating factors in cardiogenic pulmonary oedema
Outline ED treatment modalities
Objectives

3. Pulmonary oedema = fluid translocation into alveolar air spaces due to changes in pulmonary capillary properties
Due to either
altered capillary permeability(‘leakiness’)
Altered transmembrane pressure gradient
Two distinct groups –
High (>20mmHg) pulmonary capillary pressure (‘Cardiogenic’)
Low (<20mmHg) pulmonary capillary pressure
(‘Non-cardiogenic’)
Pathophysiology

4. Cardiogenic pulmonary oedema
Progressive, accelerating cycle
Accumulation of fluids
alveolar collapse
loss of lung capacity(FRC)
increased work of breathing to inflate ‘waterlogged’ lung
Cardiogenic pulmonary oedema

5. Cardiogenic pulmonary oedema = syndrome of ‘transient’ LV failure
WHY does this individual have cardiogenic pulmonary oedema?
~40-60% will have normal LVEF; not oedematous
NOT synonymous with ‘CHF’
Raises concept of ‘diastolic’ vs ‘systolic’ LV failure
Cardiac failure?

6. Systolic/Diastolic failure

7. Other acute causes APO may have several other acute causes
-’Pump failure’
- Valve failure
RVF in isolation (eg chronic pulmonary disease) does not cause APO
Overlaps possible
Other acute causes

8. Precipitants Frequently an acute triggering event Coronary event
Needs to be sought and corrected if possible
Mnemonic – ‘CHIVE MAN’
Coronary event
Hypertensive episode
Infection
Volume overload/Valve
Embolism
Medication changes
Arrhythmia(AF)
Non-compliance
Precipitants

9. Management Principles of treatment -Reverse hypoxia -Reduce WoB
-Decrease SVR
-Improve cardiac output
-Seek and remove triggering factors
Management

10. Breathing High flow O2 to keep Sats >95% NIPPV as soon as available
PEEP recruits collapsed alveoli
Reduces WoB and restores FRC with each breath cycle
CPAP/BiPAP equally efficacious at reducing need for intubation
Potential for hypotension
10-30% mask intolerance
Breathing

11. Circulation Aim to reduce preload and afterload to assist failing LV
PEEP reduces both by instituting intra-thoracic pressure
Effect can be increased by use of nitrates
GTN SL or by infusion. GTN 600mcg SL q 5 equivalent to 60mcg/min infusion
Action primarily by venodilation + preload reduction
May cause hypotension. Avoid in Aortic Stenosis
Circulation

12. Diuretics Mainstay of treatment for 40 + yrs
Primarily useful in volume overload APO
Utility in hypertensive diastolic LVF?
Postulated to have venodilating and diuretic effect
Frusemide should produce diuresis in 15-20mins
Diuretics

13. CXR – Confirmatory for diagnosis; exclude other causes of severe dyspnoea
ECG – ACS; arrhythmia
FBC – Check for anaemia
UEC – Na, K and renal parameters. Consider checking Mg
Troponin – ACS ; beware high sensitivity results
BNP ?- Clinical APO more sensitive and specific.
ABG? – Not required
Investigations

14. Challenging scenarios
APO in the Dialysis patient
APO with rapid AF
APO with hypotension
Challenging scenarios

15. APO and the dialysis pt Often true volume overload
Prone to all other causes of LVF however!!
Unable to remove salt/H2O
Often respond well to NIPPV/nitrates
Require emergent transfer to acute dialysis centre/ICU
APO and the dialysis pt

16. Check for background history of AF and if rate appropriate
New onset AF requires control
Avoid –ve inotrope
Amiodarone 5mg/kg q 60min
If fails with clinical deteriorationcardioversion
Digoxin unlikely to help acutely
APO and rapid AF

17. APO and hypotension Potentially = cardiogenic shock
Check to ensure PEEP correct
Assess cause and prognosis
Senior intervention with Cardiology and ICU
STEMI/ACS  Retrieve to Cath. Centre (?Cardiothoracic)
Dobutamine mcg/kg/min OR
Adrenaline mcg/kg/min
Consider early intubation (high risk)
APO and hypotension

18. Questions?

19. Summary APO = syndrome, not a diagnosis
APO is due to LV failure which may be either due to systolic or diastolic failure
NIPPV improves both oxygenation and cardiac performance
Seek precipitating causes and treat
Beware the hypotensive APO patient
Summary