acute pulmonary edema

WordNet

1. of critical importance and consequence; "an acute (or critical) lack of research funds"
2. having or demonstrating ability to recognize or draw fine distinctions; "an acute observer of politics and politicians"; "incisive comments"; "icy knifelike reasoning"; "as sharp and incisive as the stroke of a fang"; "penetrating insight"; "frequent penetrative observations" (同)discriminating, incisive, keen, knifelike, penetrating, penetrative, piercing, sharp
3. extremely sharp or intense; "acute pain"; "felt acute annoyance"; "intense itching and burning" (同)intense
4. having or experiencing a rapid onset and short but severe course; "acute appendicitis"; "the acute phase of the illness"; "acute patients"
5. of an angle; less than 90 degrees
6. swelling from excessive accumulation of watery fluid in cells, tissues, or serous cavities (同)oedema, hydrops, dropsy

PrepTutorEJDIC

1. (先の)『鋭い』,とがった / (痛み・感情などが)『激しい』,強い / (知力・感覚などが)『鋭い』,鋭敏な / (事態が)重大な / (病気が)急性の / (音が)高い,鋭い / 鋭角の
2. 浮腫(ふしゅ),水腫
3. 肺の;肺を冒す

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2016/05/05 17:38:38」(JST)

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Pulmonary edema
Pulmonary edema with small pleural effusions on both sides.
Classification and external resources
Specialty	Cardiology, critical care medicine
ICD-10	J81
ICD-9-CM	514 518.4
DiseasesDB	11017
MedlinePlus	000140
eMedicine	article/157452 article/300813, article/360932
MeSH	D011654

Pulmonary edema (American English), or oedema (British English; both words from the Greek οἴδημα), is fluid accumulation in the air spaces and parenchyma of the lungs. It leads to impaired gas exchange and may cause respiratory failure. It is due to either failure of the left ventricle of the heart to adequately remove blood from the pulmonary circulation ("cardiogenic pulmonary edema"), or an injury to the lung parenchyma or vasculature of the lung ("noncardiogenic pulmonary edema"). Treatment is focused on three aspects: firstly improving respiratory function, secondly, treating the underlying cause, and thirdly avoiding further damage to the lung. Pulmonary edema, especially acute, can lead to fatal respiratory distress or cardiac arrest due to hypoxia. It is a cardinal feature of congestive heart failure.

Signs and symptoms

The overwhelming symptom of pulmonary edema is difficulty breathing, but may also include coughing up blood (classically seen as pink, frothy sputum), excessive sweating, anxiety, and pale skin. Shortness of breath can manifest as orthopnea (inability to lie down flat due to breathlessness) and/or paroxysmal nocturnal dyspnea (episodes of severe sudden breathlessness at night). These are common presenting symptoms of chronic pulmonary edema due to left ventricular failure. The development of pulmonary edema may be associated with symptoms and signs of "fluid overload"; this is a non specific term to describe the manifestations of left ventricular failure on the rest of the body and includes peripheral edema (swelling of the legs, in general, of the "pitting" variety, wherein the skin is slow to return to normal when pressed upon), raised jugular venous pressure and hepatomegaly, where the liver is enlarged and may be tender or even pulsatile. Other signs include end-inspiratory crackles (sounds heard at the end of a deep breath) on auscultation and the presence of a third heart sound.

Causes

Pulmonary edema on CT-scan (coronal MPR)

Pulmonary edema is an accumulation of fluid within the parenchyma and air spaces of the lungs. Classically it is cardiogenic (left ventricular) but fluid may also accumulate due to damage to the lung. This damage may be direct injury or injury mediated by high pressures within the pulmonary circulation. When directly or indirectly caused by increased left ventricular pressure pulmonary edema may form when mean pulmonary pressure rises from the normal of 15 mmHg to above 25 mmHg. Broadly, the causes of pulmonary edema can be divided into cardiogenic and non-cardiogenic. By convention cardiogenic refers to left ventricular causes.

Cardiogenic

• Congestive heart failure which is due to the heart's inability to pump the blood out of the pulmonary circulation at a sufficient rate resulting in elevation in wedge pressure and pulmonary edema - this may be due to left ventricular failure, arrhythmias, or fluid overload, e.g., from kidney failure or intravenous therapy.
• Hypertensive crisis can cause pulmonary edema as the elevation in blood pressure and increased after load on the left ventricle hinders forward flow and causes the elevation in wedge pressure and subsequent pulmonary edema.

Non-cardiogenic

• Negative pressure pulmonary edema in which a significant negative pressure in the chest (such as from an inhalation against an upper airway obstruction) ruptures capillaries and floods the alveoli.
• Neurogenic causes (seizures, head trauma, strangulation, electrocution).
• Acute respiratory distress syndrome

Other

Injury to the lung may also cause pulmonary edema through injury to the vasculature and parenchyma of the lung. The acute lung injury-acute respiratory distress syndrome (ALI-ARDS) covers many of these causes, but they may include:

• Inhalation of hot or toxic gases
• Pulmonary contusion, i.e., high-energy trauma (e.g. vehicle accidents)
• Aspiration, e.g., gastric fluid
• Reexpansion, i.e. post large volume thoracocentesis, resolution of pneumothorax, post decortication, removal of endobronchial obstruction, effectively a form of negative pressure pulmonary oedema.
• Reperfusion injury, i.e. postpulmonary thromboendartectomy or lung transplantation
• Immersion pulmonary edema
• Multiple blood transfusions
• Severe infection or inflammation which may be local or systemic. This is the classical form of ALI-ARDS.

Some causes of pulmonary edema are less well characterised and arguably represent specific instances of the broader classifications above.

• Arteriovenous malformation
• Hantavirus pulmonary syndrome
• High altitude pulmonary edema (HAPE)
• Envenomation, such as with the venom of Atrax robustus
• Flash pulmonary edema
• Swimming induced pulmonary edema

Diagnosis

X-Ray showing pulmonary oedema

There is no one single test for confirming that breathlessness is caused by pulmonary edema; indeed, in many cases, the cause of shortness of breath is probably multifactorial.

Low oxygen saturation and disturbed arterial blood gas readings support the proposed diagnosis by suggesting a pulmonary shunt. Chest X-ray will show fluid in the alveolar walls, Kerley B lines, increased vascular shadowing in a classical batwing peri-hilum pattern, upper lobe diversion (increased blood flow to the superior parts of the lung), and possibly pleural effusions. In contrast, patchy alveolar infiltrates are more typically associated with noncardiogenic edema

Especially in the case of cardiogenic pulmonary edema, urgent echocardiography may strengthen the diagnosis by demonstrating impaired left ventricular function, high central venous pressures and high pulmonary artery pressures.

Blood tests are performed for electrolytes (sodium, potassium) and markers of renal function (creatinine, urea). Liver enzymes, inflammatory markers (usually C-reactive protein) and a complete blood count as well as coagulation studies (PT, aPTT) are also typically requested. B-type natriuretic peptide (BNP) is available in many hospitals, sometimes even as a point-of-care test. Low levels of BNP (<100 pg/ml) suggest a cardiac cause is unlikely.

Prevention

In those with underlying heart disease, effective control of congestive symptoms prevents pulmonary edema.

Dexamethasone is in widespread use for the prevention of high altitude pulmonary edema. Sildenafil is used as a preventive treatment for altitude-induced pulmonary edema and pulmonary hypertension, the mechanism of action is via phosphodiesterase inhibition which raises cGMP, resulting in pulmonary arterial vasodilation and inhibition of smooth muscle cell proliferation. While this effect has only recently been discovered, sildenafil is already becoming an accepted treatment for this condition, in particular in situations where the standard treatment of rapid descent has been delayed for some reason.

Management

The initial management of pulmonary edema, irrespective of the type or cause, is supporting vital functions. Therefore, if the level of consciousness is decreased it may be required to proceed to tracheal intubation and mechanical ventilation to prevent airway compromise. Hypoxia (abnormally low oxygen levels) may require supplementary oxygen, but if this is insufficient then again mechanical ventilation may be required to prevent complications. Treatment of the underlying cause is the next priority; pulmonary edema secondary to infection, for instance, would require the administration of appropriate antibiotics.

Cardiogenic pulmonary edema

Acute cardiogenic pulmonary edema often responds rapidly to medical treatment. Positioning upright may relieve symptoms. Loop diuretics such as furosemide or bumetanide are administered, often together with morphine or diamorphine to reduce respiratory distress. Both diuretics and morphine may have vasodilator effects, but specific vasodilators may be used (particularly intravenous glyceryl trinitrate or ISDN) provided the blood pressure is adequate.

Continuous positive airway pressure and bilevel positive airway pressure (BIPAP/NIPPV) has been demonstrated to reduce the need of mechanical ventilation in people with severe cardiogenic pulmonary edema, and may reduce mortality.

It is possible for cardiogenic pulmonary edema to occur together with cardiogenic shock, in which the cardiac output is insufficient to sustain an adequate blood pressure. This can be treated with inotropic agents or by intra-aortic balloon pump, but this is regarded as temporary treatment while the underlying cause is addressed.

References

External links

• HeartFailureMatters.org Animation showing How Heart Failure causes Fluid Accumulation - Created by the European Heart Failure Association

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

• 1. 非心原性肺水腫 noncardiogenic pulmonary edema
• 2. 心原性肺水腫の病態生理 pathophysiology of cardiogenic pulmonary edema
• 3. 神経原性肺水腫 neurogenic pulmonary edema
• 4. 急性非代償性心不全の評価 evaluation of acute decompensated heart failure
• 5. 急性非代償性心不全の治療：治療の要素 treatment of acute decompensated heart failure components of therapy

English Journal

• Regulation of alveolar fluid clearance and ENaC expression in lung by exogenous angiotensin II.

• Deng J, Wang DX, Deng W, Li CY, Tong J, Ma H.SourceDepartment of Respiratory Medicine, Second Affiliated of Chongqing Medical University, Chongqing, China.
• Respiratory physiology & neurobiology.Respir Physiol Neurobiol.2012 Apr 15;181(1):53-61. Epub 2011 Nov 26.
• Angiotensin II (Ang II) has been demonstrated as a pro-inflammatory effect in acute lung injury, but studies of the effect of Ang II on the formation of pulmonary edema and alveolar filling remains unclear. Therefore, in this study the regulation of alveolar fluid clearance (AFC) and the expression
• PMID 22138610

Japanese Journal

• ISP-20-2 Acute Pulmonary Edema in Preeclampsia and Gestational Hypertension : a Single-center Retrospective Study(Group 20 PIH,International Session Poster)

• 日本産科婦人科學會雜誌 68(2), 536, 2016-02-01
• NAID 110010034718

• Epstein-Barr Virus-positive T-cell Lymphoproliferative Disease Following Umbilical Cord Blood Transplantation for Acute Myeloid Leukemia

• Journal of Nippon Medical School 83(1), 35-42, 2016
• NAID 130005132782

• 急性呼吸促迫症候群(ARDS)の病態生理 (特集 ARDS)

• 呼吸器内科 = Respiratory medicine 28(2), 87-91, 2015-08
• NAID 40020566233

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関連記事	「acute」「pulmonary」

「acute」

　　[★]

• adj.

• (疾患)急性の、急性型の、急性的な。(形状が)鋭い、鋭角の。(感覚、才知などが)鋭い。明敏な、鋭い眼識のある。

関

acutely、quick、sharp

　 　 　 　 　 　

「pulmonary」

　　[★]

• adj.

• 肺の、肺性の

関

lung、pneumo