Acute Cardiogenic Pulmonary Acute Cardiogenic Pulmonary OedemaOedema

What is Pulmonary Oedema?What is Pulmonary Oedema? Acute (or Flash) pulmonary oedema is a Acute (or Flash) pulmonary oedema is a

condition in which fluid accumulates in the lungs condition in which fluid accumulates in the lungs Pulmonary oedema can be a chronic condition Pulmonary oedema can be a chronic condition

or it can develop suddenly and quickly become or it can develop suddenly and quickly become life threatening. life threatening.

Acute pulmonary oedema becomes life Acute pulmonary oedema becomes life threatening when a large amount of fluid shifts threatening when a large amount of fluid shifts from the pulmonary blood vessels into the lung from the pulmonary blood vessels into the lung

CausesCausesNon- Cardiogenic CausesNon- Cardiogenic Causes

-Lymphatic Obstruction-Lymphatic Obstruction-Excess Volume Administration-Excess Volume Administration-Decreased Oncotic Pressure (Low -Decreased Oncotic Pressure (Low Albumin) Albumin)-Damage to the Lung-Damage to the Lung

CausesCauses Cardiogenic CausesCardiogenic Causes

--Congestive Cardiac FailureCongestive Cardiac FailureBacking up of blood in Backing up of blood in Cardiopulmonary system Cardiopulmonary system Increasing hydrostatic pressure Increasing hydrostatic pressure

--Valvular Disease (Aortic and Mitral)Valvular Disease (Aortic and Mitral)?Blockage or Regurge?Blockage or Regurgeeg Aortic Stenosis- inability to eg Aortic Stenosis- inability to pump out blood from Left pump out blood from Left Ventricle Ventricle Aortic Regurge- Blood Aortic Regurge- Blood pumps out but flows back pumps out but flows back to to Left Ventricle Left Ventricle Mitral Stenosis – inability to Mitral Stenosis – inability to pump blood from left atrium pump blood from left atrium to left ventricle to left ventricle Mitral Regurge – Blood is Mitral Regurge – Blood is pumped out from Left Atrium pumped out from Left Atrium but but flows back into itflows back into it

CausesCauses ArrhythmiasArrhythmias

Ineffective pumping of Ineffective pumping of the heart due to electrical the heart due to electrical conduction so the heart does not conduction so the heart does not pump correctly thus not allowing pump correctly thus not allowing blood to be pumped out of the blood to be pumped out of the cardio-pulmonary circulationcardio-pulmonary circulation

MyocarditisMyocarditisIneffective pumping due Ineffective pumping due

to inflammationto inflammation

All 4 reasons have the same All 4 reasons have the same problem ineffective filling or problem ineffective filling or pumping of the heart causing pumping of the heart causing blood to back up in the cardio-blood to back up in the cardio-pulmonary circulation, but all have pulmonary circulation, but all have different aetiologydifferent aetiology

So what Happens?So what Happens? The heart's main chamber the left ventricle is weakened The heart's main chamber the left ventricle is weakened

and does not function properly and does not function properly The ventricle fails to completely eject its contents, The ventricle fails to completely eject its contents,

causing blood to back up and cardiac output to drop. causing blood to back up and cardiac output to drop. In response the body increases blood pressure and fluid In response the body increases blood pressure and fluid

volume to compensate for the reduced cardiac output. volume to compensate for the reduced cardiac output. This results in an increase in the force against which the This results in an increase in the force against which the

ventricle must expel blood. ventricle must expel blood. Blood backs up, forming a pool in the pulmonary blood Blood backs up, forming a pool in the pulmonary blood

vessels. vessels. Fluid leaks into the spaces between the tissues of the Fluid leaks into the spaces between the tissues of the

lungs and begins to accumulate. lungs and begins to accumulate.

PathophysiologyPathophysiology Pulmonary capillaries have a Pulmonary capillaries have a

hydrostatic pressure (blood hydrostatic pressure (blood pressure) of 10mmHg and an pressure) of 10mmHg and an oncotic pressure of 25mmHg oncotic pressure of 25mmHg

This balance allows fluid to This balance allows fluid to constantly move into the constantly move into the capillaries and keep the alveoli dry capillaries and keep the alveoli dry allowing for adequate gas allowing for adequate gas exchange exchange

But, if pulmonary blood pressure But, if pulmonary blood pressure rises above 25mmHg, fluid will rises above 25mmHg, fluid will accumulate in the lungs and accumulate in the lungs and interstitial tissues interstitial tissues

The Golden Rule: Pulmonary The Golden Rule: Pulmonary oedema occurs when pulmonary oedema occurs when pulmonary capillary pressure exceeds capillary pressure exceeds alveolar interstitial pressure alveolar interstitial pressure

Starlings LawStarlings Law Q=K(PQ=K(Pcapcap-P-Pintint) – ) – (p(pcapcap-p-pintint) ) Q = tendency for fluid to cross pulmonary Q = tendency for fluid to cross pulmonary

capillaries into alveolar space capillaries into alveolar space K & K & = coefficient constant of capillary wall = coefficient constant of capillary wall PPcapcap = capillary hydrostatic pressure = capillary hydrostatic pressure PPintint = pulmonary interstitial (alveolar) pressure = pulmonary interstitial (alveolar) pressure ppcapcap = capillary oncotic pressure = capillary oncotic pressure ppintint= interstitial oncotic pressure = interstitial oncotic pressure

As Q increases pulmonary oedema develops As Q increases pulmonary oedema develops

So how does Q increase?So how does Q increase? Q increases through a Q increases through a

self-perpetuating self-perpetuating cycle that leads to an cycle that leads to an increase in capillary increase in capillary hydrostatic pressure hydrostatic pressure and therefore oedema and therefore oedema

The Effect of Fluid on the LungThe Effect of Fluid on the Lung

How does it develop?How does it develop? Pulmonay Oedema develops in 3 stagesPulmonay Oedema develops in 3 stages STAGE ONESTAGE ONE - - fluid moves from the capillaries fluid moves from the capillaries

into the interstitium and hence increases into the interstitium and hence increases lymphatic flowlymphatic flow

STAGE TWOSTAGE TWO - - maximum lymphatic drainage is maximum lymphatic drainage is reached and fluid accumulates in the intestitial reached and fluid accumulates in the intestitial spaces surrounding the bronchioles and lung spaces surrounding the bronchioles and lung vasculaturevasculature

STAGE THREESTAGE THREE - - increasing pressure causes increasing pressure causes fluid to move into the interstial space around the fluid to move into the interstial space around the alveoli, disrupting the alveolar membranes and alveoli, disrupting the alveolar membranes and finally flooding the alveolifinally flooding the alveoli

Signs and symptomsSigns and symptoms shortness of breath (dyspnea) shortness of breath (dyspnea) wheezing wheezing anxiety anxiety restlessness restlessness cough with a frothy or pink sputum cough with a frothy or pink sputum pale skin pale skin blood stained sputum blood stained sputum fine crackles on auscultation fine crackles on auscultation elevated JVP elevated JVP increased weight increased weight excessive sweating excessive sweating orthopnea orthopnea tachycardia tachycardia hypertension hypertension cold extremeties (cyanosis) cold extremeties (cyanosis) extensive use of accessory muscles of extensive use of accessory muscles of

respi respi

DiagnosisDiagnosis Remember ABCDERemember ABCDE The patient should be tachypnoeic as they are wanting The patient should be tachypnoeic as they are wanting

to breathe, if resp rate slow and sats<92% patient is in to breathe, if resp rate slow and sats<92% patient is in respiratory distress and may need intubation as fatiguingrespiratory distress and may need intubation as fatiguing

Diagnosis of acute pulmonary oedema is made by Diagnosis of acute pulmonary oedema is made by questioning the patient about any previous history of questioning the patient about any previous history of cardiac or pulmonary disease, previous episodes of cardiac or pulmonary disease, previous episodes of pulmonary oedema or cardiac failure and the use of any pulmonary oedema or cardiac failure and the use of any medications. medications.

A physical examination of the patient is performed to A physical examination of the patient is performed to assess for signs of ventricular failure, manifestations of assess for signs of ventricular failure, manifestations of dyspnea and signs of hypoxia and fluid in the lungs dyspnea and signs of hypoxia and fluid in the lungs

Blood TestsBlood TestsBlood testsBlood tests::Renal Function, electrolytes, glucose, Renal Function, electrolytes, glucose,

cardiac markers, LFTs, clotting tests cardiac markers, LFTs, clotting tests (INR).(INR).

Arterial Blood Gases and pH.Arterial Blood Gases and pH.Brain natriuretic peptides - helpful in Brain natriuretic peptides - helpful in

distinguishing acute pulmonary oedema distinguishing acute pulmonary oedema from other causes of dyspnoeafrom other causes of dyspnoea

Looking at the HeartLooking at the Heart ECGECG: look for evidence of arrhythmia, myocardial : look for evidence of arrhythmia, myocardial

infarction or other cardiac disease - eg, infarction or other cardiac disease - eg, left ventricular left ventricular hypertrophy hypertrophy

EchocardiogramEchocardiogram: The test can help diagnose a number : The test can help diagnose a number of heart problems, of heart problems, It also accurately measures the amount of blood It also accurately measures the amount of blood your left ventricle ejects with each heartbeat your left ventricle ejects with each heartbeat

(ejection fraction, or EF).(ejection fraction, or EF).It can also estimate if there's increased pressure It can also estimate if there's increased pressure

in in the right side of the heart. the right side of the heart. Although a low EF often indicates a cardiac cause Although a low EF often indicates a cardiac cause for pulmonary edema, it's possible to have cardiac for pulmonary edema, it's possible to have cardiac pulmonary edema with a normal EF. pulmonary edema with a normal EF.

Signs on Chest X-RaySigns on Chest X-Ray

Looking at the Chest X-RayLooking at the Chest X-Ray Look for Alveolar Look for Alveolar

infiltratesinfiltrates Oedema usually seen Oedema usually seen

in lower lung zones in lower lung zones (pt stood or sitting up)(pt stood or sitting up)

Can be seen Can be seen everywhere if patient everywhere if patient has been lying downhas been lying down

Looking at the Chest X-RayLooking at the Chest X-Ray Hilar Obscurity is frequent Hilar Obscurity is frequent

as the oedema masks the as the oedema masks the blood vesselsblood vessels

Enlarged Cardiac Enlarged Cardiac Sillhouette – chronic Sillhouette – chronic condition as the heart has condition as the heart has enlarged to pump more enlarged to pump more powerfully eg systolic powerfully eg systolic CCF or chronic valvular CCF or chronic valvular diseasedisease

Looking at the Chest X-RayLooking at the Chest X-Ray Normal cardiac sillhouette Normal cardiac sillhouette

indicates diastolic CCF or an indicates diastolic CCF or an acute cause acute cause eg valvular rupture due to MI, eg valvular rupture due to MI, Myocarditis, Arrhythmia, Myocarditis, Arrhythmia, Volume OverloadVolume Overload

When fluid leaks into the When fluid leaks into the peripheral interlobular septa it peripheral interlobular septa it is seen as Kerley B or septal is seen as Kerley B or septal lines. lines. Short 1-2 cm horizontal lines Short 1-2 cm horizontal lines near the costophrenic angles near the costophrenic angles

Looking at the Chest X-RayLooking at the Chest X-Ray Lateral Decubitis CXRLateral Decubitis CXR Good for patients Good for patients

without blatant without blatant symptoms of symptoms of pulmonary oedema pulmonary oedema but may have an but may have an effusioneffusion

Much more sensitive Much more sensitive at showing collections at showing collections of fluidof fluid

Medical TreatmentMedical TreatmentMain worry is the lungs at this point rather Main worry is the lungs at this point rather

than the heartthan the heartTreatment of acute pulmonary oedema is Treatment of acute pulmonary oedema is

aimed at maximizing pulmonary interstitial aimed at maximizing pulmonary interstitial capillary pressure while minimizing capillary pressure while minimizing capillary hydrostatic pressure capillary hydrostatic pressure

Medical management is a two-tier Medical management is a two-tier approach combining the use of ventilation approach combining the use of ventilation and pharmacological drugs. and pharmacological drugs.

The patientThe patient

Sit the patient upright as it drains the fluid Sit the patient upright as it drains the fluid down to the bottom of the lungs, thus not down to the bottom of the lungs, thus not covering the whole of the lungs as if they covering the whole of the lungs as if they were supinewere supine

Administer OAdminister O2 2 therapy 15L/min via non-therapy 15L/min via non-rebreathe facemaskrebreathe facemask

Pharmacological TreatmentPharmacological Treatment Aim: to lower pulmonary hydrostatic Aim: to lower pulmonary hydrostatic

pressurepressure The initial treatment is aimed at decreasing LV The initial treatment is aimed at decreasing LV

preload with the use of nitroglycerin preload with the use of nitroglycerin Nitroglycerin results in vasodilation which Nitroglycerin results in vasodilation which

decreases venous return leading to decreases in decreases venous return leading to decreases in the volume in the pulmonary vascular bed the volume in the pulmonary vascular bed

This allows the LV to catch up This allows the LV to catch up

Pharmacological TreatmentPharmacological Treatment Reductions in LV after load can also be Reductions in LV after load can also be

achieved with the use of ACE Inhibitors achieved with the use of ACE Inhibitors (Captopril)(Captopril)

The ACE inhibitors (captopril) achieve this by The ACE inhibitors (captopril) achieve this by decreasing PVR leading to decreases in LV after decreasing PVR leading to decreases in LV after load load

The decrease in LV afterload causes increases The decrease in LV afterload causes increases in CO and LV ejection fraction allowing drainage in CO and LV ejection fraction allowing drainage of the pulmonary vessels of the pulmonary vessels

Captopril also decreases the adrenergic tone of Captopril also decreases the adrenergic tone of the myocardium allowing increases in end-the myocardium allowing increases in end-diastolic volume & CO diastolic volume & CO

Pharmacological TreatmentPharmacological Treatment After initial treatment, diuretics (Furosemide) can After initial treatment, diuretics (Furosemide) can

be used to reduce LV preload by decreasing be used to reduce LV preload by decreasing blood volumeblood volume

Morphine is also commonly administred to Morphine is also commonly administred to patients to reduce anxiety, decrease patients to reduce anxiety, decrease sympathetic outflow and cause venodilation and sympathetic outflow and cause venodilation and decrease preload decrease preload

Inhaled beta-adrenergic agonists may be Inhaled beta-adrenergic agonists may be administered to treat the bronchospasm that administered to treat the bronchospasm that may occur in response to the pulmonary may occur in response to the pulmonary oedemaoedema

Advanced OAdvanced O2 2 TherapyTherapy

CPAPCPAP is one technique used to lessen the is one technique used to lessen the symptoms experienced by the patient symptoms experienced by the patient

CPAPCPAP assists patients in three ways: assists patients in three ways: 1.Decrease Work of Breathing 1.Decrease Work of Breathing

-by preventing alveoli collapse -by preventing alveoli collapse 2.Enhanced Gas Exchange 2.Enhanced Gas Exchange

-improves V/Q mismatch & lung -improves V/Q mismatch & lung compliance compliance 3.Improved Hemodynamics 3.Improved Hemodynamics

-decrease venous return to LV and -decrease venous return to LV and decreases pre-load decreases pre-load

Using the MDTUsing the MDT Physios can also help in the medical management Physios can also help in the medical management Active Cycle of Breathing ExercisesActive Cycle of Breathing Exercises

-reduces anxiety and increases O2 -reduces anxiety and increases O2 Incentive SpirometryIncentive Spirometry -increases lung vol and encourages basal expansion to reduce the work of -increases lung vol and encourages basal expansion to reduce the work of breathing breathing Respiratory Muscle ExercisesRespiratory Muscle Exercises -decrease WOB -decrease WOB PEP devicePEP device -maintains lung volume and facilitate clearance -maintains lung volume and facilitate clearance Oxygen TherapyOxygen Therapy --improves perfusion and VE/Q mismatch improves perfusion and VE/Q mismatch Patient positioning (sitting up)Patient positioning (sitting up) -decreases WOB, reduce venous return & increases FRC -decreases WOB, reduce venous return & increases FRC Gravity Assisted Positioning with PercussionsGravity Assisted Positioning with Percussions -enhances airway clearance -enhances airway clearance Suction & Manual HyperinflationSuction & Manual Hyperinflation -used in intubated patient -used in intubated patient

What caused it?What caused it? Identify and address underlying cause as Identify and address underlying cause as

a preventitive measure a preventitive measure This is the reason for obtaining the bloods, This is the reason for obtaining the bloods,

ECG, ECHO, CXRECG, ECHO, CXRFor example if its known patient has CCF, For example if its known patient has CCF,

or arrhythmias we could treat the cause or arrhythmias we could treat the cause So the causes can be treated to hopefully So the causes can be treated to hopefully

reduce the chance of it continuing reduce the chance of it continuing orreoccuringorreoccuring

Case Study 1Case Study 1What symptoms would you seen in early What symptoms would you seen in early

stages?stages?

What happens to the patient?What happens to the patient? In early stages of pulmonary oedema the In early stages of pulmonary oedema the

patient feels as though they cannot get their patient feels as though they cannot get their breathbreath

Resp Rate, blows off COResp Rate, blows off CO2 2 faster than can faster than can compensate with bicarbonatecompensate with bicarbonate

pCOpCO2 2 pHpH Normal HCONormal HCO33 Respiratory AlkalosisRespiratory Alkalosis

Case StudyCase StudyWhat happens to the patient and what What happens to the patient and what

symptoms would you see in later stages?symptoms would you see in later stages?

What happens to the patient?What happens to the patient? The patient in between early and late stages The patient in between early and late stages

patient will have a normal range ABGpatient will have a normal range ABG

In later stages of pulmonary oedema the patient In later stages of pulmonary oedema the patient due to respiratory fatigue due to respiratory fatigue

Resp RateResp Rate pHpH pCOpCO22 Normal HCONormal HCO33 Respiratory AcidosisRespiratory Acidosis

SummarySummaryAcute pulmonary oedema is a life Acute pulmonary oedema is a life

threatening condition and proper threatening condition and proper management of the underlying cause is management of the underlying cause is essential in preventing its onset essential in preventing its onset

Prevention can be aided by treating the Prevention can be aided by treating the underlying cause of heart disease underlying cause of heart disease

Sometimes it may be known as Sometimes it may be known as ““Flash Oedema”Flash Oedema”

FlashFlash