Pulmonary Edema

what is the definition of pulmonary edema?

movement of excessive fluid from vascular bed into extravascular spaces and alveoli

how did Kathy number the movement of the fluid

1. perivascular

2. peribronchial

3. alveoli

4. bronchioles

5. bronchi

how does pulmonary edema cause atelectasis

PE results in swelling of alveolar walls and interstitial spaces.

this causes increased surface tension (due to lack of surfactant) and leads to atelectasis

what type of secretions are seen in PE patients. where does it come frm

pink to white frothy secretions.

pink comes from red blood cells

air (froth) comes from the air moving out of the alveoli

what vessels are also enlarged in PEs

enlarged lymphatic vessels and flow

what would the PFT of PE show

restrictive. decreased diffiusion and V/Q abnormality

what are the 2 major classifications of PE

1. cardiogenic

2. noncardiogenic

what is included in cardiogenic PE

left heart failure (CHF)

what is included in noncardiogenic PE

• increases capillary permeability

• lymphatic insuficiency

• decreased intrapleural pressure

• decreased oncotic pressure

what is happening in cardiogenic PE and what is it also known as

heart is not pumping properly, which causes an increased afterload. The fluid backs up into the pulmonary vasculature bed.

left ventricular failure

what population is CHF prevelant in

African americans; 65 years old

what causes left ventricular failure

increased pulmonary veins and capillary pressures

how does hydrostatic pressure affect the heart? What is the normal amount?

increased hydrostatic pressure throws the pressure balances off leading to fluid leaking from the capillaries into the interstitium of the lung.

Normal is 10 - 15; when >30, it leaks out of the capillary bed into the interstitium of the lung

what are signs of cardiogenic PE

fatigue

crackles

wheezes

diaphoresis

cyanosis of digits

peripheral pallor

what are symptoms of cardiogenic PE

anxiety

delirium

orthopnea

paroxysmal

nocturnal dyspnea

cough

increased fremitus

what are the other causes of cardiogenic pulmonary edema

• dysrhythmia resulting in decreased cardiac output

• systemic hypertension

• congenital heart defects

• excessive fluid administration

• mitral or aortic valve disease

• cardiac tamponade

• pulmonary embolus

• renal failure

• rheumatic heart disease

• cardiomyopathies

what are the causes of non cardiac PE

• increased capillary permeability

• lymphatic insufficiency

• decreased intrapleural pressure

• decreased oncotic pressure

what causes increased capillary permeability in non cardiac PE

• damage to the capillary due to inflammation or infection

• hypoxia

• ARDS

• inhalation of toxic agents

• pneumonia

• thoracic radiation

• acute head injury

what causes lymphatic insufficiency in non cardiac PE

• decreased drainage caused by

  • destruction of vessels

  • obstructed by tumor

  • lung transplantation

  • increased systemin venous pressure

what causes decreased intraplueral pressure in non cardiac PE

• severe airway bostruction

• decompression pulmonary edema

what causes decreased oncotic pressure in non cardic PE

it is rare and is caused by:

• rapid delivery of fluid

• uremia

• hypoproteinemia (malnutrition)

• acute nephritis

what electrolytes are typically low in PE

Na, Cl, and K

what is usually increased and decreased in the hemodynamics of PE

increased:

• CVP (right atrium)

• pulmonary artery pressure

• vascular resistance

• pulmonary capillary wedge pressure (left atrium)

decreased:

• cardiac output

what does it mean when the PCWP is decreased

the pressure in the left heart is decreased

what does it mean if the PA pressure is increased

there is a problem with the pulmonary vasculature or with the left side of the heart

if the pressure in the right side of the heart is increased, what could it be related to

pulmonary hypertension

left side of the heart is failing

right ventricular hypertrophy

wherever the catheter is, it detects the pressures….

forward

what radiologic sign shows PE

batwing/butterfly pattern

enlarged heart

kerley b lines

what is the difference between kerley A and B lines

A comes from deep interstitial edema. from the hilum to central part of the lung

B are thin, short, horizontal lines of the interstitial edema that go inward from the pleura 

which type of PE has fluid more prominent near the hilum

non cardiogenic PE

what medications are used to treat PE

• antiarrthymics (beta blockers, calcium channel blockers’, amiodarone)

• positive inotropes (digitalis, dopamine, dobutamine, epinephrine)

• reduce workload ~vasodilators (nitroglycerin, nitroprussides, alpha blockers, angiotensin converting enzyme inhibitors (ACE)(causes cough))

• sodium and fluid retention therapy (diet, diuretics)

• albumin and mannitol (increase oncotic pressure)

what is the difference between a positive inotrope and negative inotrope

positive inotrope ~ stronger contractility

negative intrope ~ weaker contractility

what are the RT protocols for PE

• oxygen (due to shunting in PE pts being increased)

• bronchial hygiene

• CPAP

• bronchodilators 

• alcohol 

why are there issues with suctioning pts with PE

suctioning can improve the secretions seen at the moment, but it can also pull fluids back into the airways by changing the intrathoracic pressure and the secretions would still be there

why is CPAP the best treatment for PE patients

it gives pressure

surfactant is washed away by the PE and there is reduced FRC, CPAP increases the FRC

why does bronchodilators usually not work for wheezzing PE patients

the wheezing is caused by edema

what does alcohol do to the alveoli

reduces surface tension