AcuteAcute PulmonaryPulmonary OedemaOedema andand PulmonaryPulmonary EmbolismEmbolism
Dr Arthur Chun-Wing LAU 劉俊穎劉俊穎 Associate Consultant Department of Intensive Care Pamela Youde Nethersole Eastern Hospital
25 August 2008 PathogenesisPathogenesis
1. PulmonaryPulmonary edemaedema CardiogenicCardiogenic NonNon--cardiogeniccardiogenic (e.g.(e.g. acuteacute lunglung injuryinjury (ALI),(ALI), acuteacute respiratoryrespiratory distressdistress syndromesyndrome (ARDS)(ARDS) 2. PulmonaryPulmonary embolismembolism CardiogenicCardiogenic pulmonarypulmonary edemaedema
Normal lung Pulmonary edema CaseCase
M/62M/62 C/oC/o progressiveprogressive SOB,SOB, nonnon--productiveproductive cough,cough, lowlow gradergrader feverfever xx 33 daysdays PastPast health:health: CHFCHF 22 yearsyears agoago P/E:P/E: BPBP 95/5595/55 mmHgmmHg，，PP 110110，，TT 37.937.9℃℃,, SpO2SpO2 96%96% inin RARA Chest:Chest: bilateralbilateral ralesrales andand rhonchirhonchi CommonCommon causescauses ofof APO/CHFAPO/CHF
Acute Chronic Both
Myocardial infarction Coronary artery disease Hypertension
Myocarditis Diabetes: systolic and diastolic dysfucntion Dysrhythmias Alcoholic cardiomyopathy
Valvular heart disease (esp aortic and mitral) CHFCHF ViciousVicious CycleCycle
Low Output
Increased Preload Increased Afterload Norepinephrine
Increased Salt Vasoconstriction Renal Blood Flow
Renin Angiotension I Angiotension II Aldosterone SymptomsSymptoms
AnkleAnkle edemaedema SevereSevere resp.resp. distress:distress: orthopneaorthopnea,, dyspneadyspnea,, paroxysmalparoxysmal nocturnalnocturnal dyspnea.dyspnea. SevereSevere apprehension,apprehension, agitation,agitation, confusion,confusion, diaphoresis:diaphoresis: ResultsResults fromfrom sympatheticsympathetic stimulationstimulation SignsSigns
Vitals increase in sympathetic discharge to compensate. BP — elevated Pulse rate — elevated to compensate for decreased stroke volume. Respirations — rapid and labored, desaturation and cyanosis Diaphoresis Pulmonary congestion Rales—especially at the bases. Rhonchi—associated with fluid in the larger airways Wheezes Jugular Venous Distention Comes from back pressure building from right heart into venous circulation Ankle edema, congested liver InvestigationsInvestigations
ECG:ECG: looklook forfor cardiaccardiac ischaemiaischaemia Echo:Echo: checkcheck cardiaccardiac function,function, valvularvalvular functionfunction BB--typetype NatriureticNatriuretic PeptidePeptide (BNP):(BNP): lowlow levelslevels ofof BNPBNP (<100(<100 pg/ml)pg/ml) makemake aa cardiaccardiac causecause veryvery unlikelyunlikely
LeftLeft vsvs RightRight--sideside HFHF
LeftLeft--sidedsided isis associatedassociated withwith dyspneadyspnea,, fatigue,fatigue, weakness,weakness, cough,cough, PND,PND, orthopneaorthopnea andand JVDJVD RightRight--sidedsided isis associatedassociated withwith peripheralperipheral edema,edema, JVD,JVD, RUQRUQ pain,pain, hepatojugularhepatojugular reflexreflex SystolicSystolic vsvs DiastolicDiastolic HFHF
Systolic HF impaired contractility leads to increased cardiac volumes and pressure, and afterload sensitivity With stress, failure to improve cardiac contractility, despite increasing venous return results in increased cardiac pressures, pulmonary congestion and edema
Diastolic HF decreased LV compliance and higher atrial pressures results in preload sensitivity Decreased LV compliance necessitates higher atrial pressures to ensure adequate diastolic LV filling
TreatmentTreatment
100% O2 by face mask to obtain saturation >95% Airway control and adequate ventilation: NIV or MV Sit up 45 degrees Promotion of rest, Relief of anxiety Diuretics: e.g. lasix 40-80 mg IV Control myocaridal ischaemia: aspirin, thrombolytic agents, nitrate, beta-blocker Vasodilators: nitrates, ACEI, Ca channel blocker Control hypertension: nitrate, ACEI, nitroprusside, Ca channel blockers, hydralazine If hypotensive or need for iontropic support: dopamine 5-10 ug/kg/min, dobutamine, digoxin Treat coexisiting arrhythmia or electrolyte disturbance Morphine use PRN Fluid removal in renal shutdown: haemofiltration, haemodialysis Intraaortic ballon pump LV remodelling: ACEI Facial Nasal
Nasal pillow Total face VasodilatorVasodilator
DilateDilate bloodblood vesselsvessels OftenOften constrictedconstricted duedue toto activationactivation ofof thethe sympatheticsympathetic nervousnervous systemsystem andand thethe reninrenin-- angiotensinangiotensin--aldosteronealdosterone system.system. CommonCommon ACEACE inhibitorsinhibitors PerindoprilPerindopril LisinoprilLisinopril CaptoprilCaptopril NitratesNitrates DiureticsDiuretics
LasixLasix Hydrochlorothiazide(HCTZ)Hydrochlorothiazide(HCTZ) SpironolactoneSpironolactone
TheseThese inhibitinhibit reabsorptionreabsorption ofof Na+Na+ intointo thethe kidneyskidneys CalciumCalcium channelchannel blockerblocker
UsedUsed toto dilatedilate bloodblood vesselsvessels UsedUsed mostlymostly withwith CHFCHF inin thethe presencepresence ofof ischemiaischemia ExamplesExamples Nifedipine Diltiazem Verapamil Amlodipine Felodipine BetaBeta blockersblockers
UsefulUseful byby blockingblocking thethe betabeta--adrengergicadrengergic receptorsreceptors ofof thethe sympatheticsympathetic nervousnervous system,system, thethe heartheart raterate andand forceforce ofof contractilitycontractility areare decreaseddecreased couldcould actuallyactually worsenworsen CHFCHF
ExamplesExamples Metoprolol Atenolol Propanolol Amiodarone InotropicInotropic agentsagents
DopamineDopamine DobutamineDobutamine DigoxinDigoxin
IncreasesIncreases thethe contractilitycontractility ofof thethe heartheart increasingincreasing thethe cardiaccardiac outputoutput PreventPrevent thethe productionproduction ofof thethe chemicalschemicals thatthat causescauses bloodblood vesselsvessels toto narrownarrow ResultingResulting inin bloodblood pressurepressure decreasingdecreasing andand thethe heartheart pumpingpumping easiereasier NonNon cardiogeniccardiogenic pulmonarypulmonary edemaedema CausesCauses ofof nonnon--cardiogeniccardiogenic APOAPO (=(= ALI,ALI, ARDS)ARDS)
Inhalation of toxic gases Multiple blood transfusions Severe infection Pulmonary contusion, i.e., Multitrauma, e.g., severe car accident Neurogenic, e.g., subarachnoid hemorrhage Aspiration, e.g., gastric fluid or in case of drowning Certain types of medication Upper airway obstruction Arteriovenous malformation Reexpansion, i.e. post pneumonectomy or large volume thoracentesis Reperfusion injury, i.e. postpulmonary thromboendartectomy or lung transplantation Ascent to high altitude occasionally causes high altitude pulmonary edema (HAPE)[2] Cardiogenic pulmonary edema •Enlargement of peribronchial vascualar space •Kerley’s B lines
Non- cardiogenic pulmonary edema •E.g. pneumococcal septicaemia •Air-bronchograms •Acute lung injury/acute respiratory distress syndrome
TreatmentTreatment
VentilatoryVentilatory supportsupport DirectDirect toto underlyingunderlying causecause PulmonaryPulmonary embolismembolism InvestigationsInvestigations
18371837 FirstFirst casecase reportreport ofof PEPE 19221922 DescriptionDescription ofof signssigns atat CXRCXR 19631963 PulmonaryPulmonary angiographyangiography 19641964 LungLung scintigraphyscintigraphy 19921992 SpiralSpiral CTCT CaseCase 1:1: F/80,F/80, WKWK
HTHT // IHDIHD // CHFCHF // BronchiectasisBronchiectasis SlippedSlipped andand fell,fell, sustainedsustained ## leftleft NOF.NOF. OTOT postponedpostponed forfor 22 weeksweeks duedue toto anan episodeepisode ofof HAPHAP andand fastfast AF.AF. IntraIntra--opop hypotensionhypotension withwith PEA.PEA. Echo:Echo: GrosslyGrossly dilateddilated RVRV SpiralSpiral CTCT thoraxthorax SpiralSpiral CTCT thoraxthorax
FillingFilling defectsdefects inin rightright superiorsuperior // inferiorinferior andand leftleft superiorsuperior PAPA andand subsegmentalsubsegmental branches.branches. ProgressProgress
ClexaneClexane (low(low molecularmolecular weightweight heparin)heparin) 60mg60mg Q12HQ12H SC.SC. NotNot forfor thrombolyticthrombolytic // embolectomyembolectomy inin viewview ofof unstableunstable haemodynamicshaemodynamics andand extensiveextensive involvement.involvement. SubsequentSubsequent ARFARF withwith anuriaanuria.. SuccumbSuccumb onon D1D1 ICUICU stay.stay. M/64,M/64, HYKHYK
HistoryHistory ofof oldold TBTB withwith rightright lobectomylobectomy.. SlipSlip andand fellfell fromfrom aa flightflight ofof stairsstairs CTCT CC--spine:spine: NoNo fracturefracture butbut cordcord impingementimpingement inin C6/7.C6/7. MRIMRI CC--spine:spine: SpinalSpinal stenosisstenosis atat C4/5.C4/5. HeterogeneousHeterogeneous signalssignals inin prepre // paravertebralparavertebral region,region, couldcould bebe oedemaoedema // haemorrhagehaemorrhage.. RehabilitationRehabilitation
AbleAble toto walkwalk wthwth frame.frame. IncreasedIncreased SOBSOB withwith desaturationdesaturation.. DifferenceDifference inin calvescalves circumference.circumference. ECG:ECG: SinusSinus tachycardia.tachycardia. RBBB.RBBB. CXR:CXR: ClearClear lunglung fields.fields. Echo:Echo: DilatedDilated RARA // RVRV withwith paradoxicalparadoxical septalseptal motionmotion andand DD--shapedshaped LVLV duringduring diastole;diastole; TR.TR.
ProgressProgress
SpiralSpiral CT:CT: FillingFilling defectsdefects inin pulmonarypulmonary trunk,trunk, bilateralbilateral pulmonarypulmonary arteriesarteries andand ththeireir segmentalsegmental branches.branches. EnoxaparinEnoxaparin 60mg60mg Q12HQ12H SCSC ++ warfarinwarfarin.. ThrombolyticsThrombolytics notnot givengiven inin viewview ofof MRIMRI findingsfindings suspicioussuspicious ofof oedemaoedema // haemorrhagehaemorrhage overover CC--spinespine.. WeanedWeaned offoff allall O2.O2. HaemodynamicsHaemodynamics remainedremained stable.stable. INRINR 1.41.4 beforebefore discharge.discharge.
HongHong KongKong DataData Data of VTE in Chinese population
Mok et al 2005 Arthritis N=625 HK VTE: 13/1000 pt-yrs Rheuma SLE Cumulative hazards at 60M after dx: 3.7% Chinese (c/w 6.6% in African-Americans, 10.3% in Caucasians)
Cheuk BL 2004 Hong Kong Chinese 6.7 All - DVT: 17.1 per 100,000; PE: 3.9 per 100,000 Br J Surg million population 65 yrs old - DVT: 81.1 per 100000; PE: 18.6 per 100,000
Hospital mortality – DVT 7.3%, PE 23.8%
Surgical (N = 120140) – DVT 0.13%/yr; PE: 0.04%/yr Lee AC 2003 N = 8 HK children 4 with DVT + PE; others SVC thrombosis, CV thrombosis, pr C def, pr S def, anti-cardiolipin, malignancy HKMJ Rates similar to Caucasians
Liu HS 2002 N = 376 352 peripheral DVT, 5 deep DVT (cerbral sinus and portal v), 40 PE (26 with concomitant DVT), 6 fatal PE at HKMJ Hong Kong autopsy Projected VTE rate in the population: 16.6 per 100,000
You JHS 2005 Hong Kong Events vs INR (see graph), aim 1.8 – 2.4 for Chinese Br J Pharmacol
Chau KY 1991 Hong Kong Retrospective review of 15 years’ autopsies Pathology Incidence of significant PE: 0.58% in first 5 yr period; 2.08% in recent yrs Conclusion: increasing incidence of pul TE
Joynt GM 2000 Hong Kong 14 out of 124 femoral venous catheterizations Chest N = 124 femoral v cats 12 line-related; 2 in the uncannulated leg Onset 1 day to 1 week after catheterization
Chau KY 1995 N = 3446 necropsies from Overall rate 3.77% J Clin Pathol 1987 - 1992 Seasona changes noted (see graph) Hong Kong Troughs in June, July, Nov, Dec: 1.6 – 2.4% Rest of months: 4.0 – 5.5% PULMONARYPULMONARY EMBOLISMEMBOLISM
90%90% ofof clinicallyclinically importantimportant PEPE resultsresults fromfrom legleg DVTDVT
96%96% ofof patientspatients withwith DVTDVT oror PEPE havehave oneone oror moremore riskrisk factorsfactors
TheThe riskrisk increasesincreases inin proportionproportion toto thethe ## ofof riskrisk factorsfactors
ProportionProportion ofof patientspatients withwith clinicallyclinically suspectedsuspected DVTDVT inin whomwhom DxDx WasWas confirmedconfirmed
## ofof DVTDVT riskrisk factorsfactors ConfirmedConfirmed DVT(%)DVT(%) 00 11%11% 11 24%24% 22 36%36% 33 50%50% 44 oror moremore 100%100%
Arch Surg 1982 DiagnosisDiagnosis ofof pulmonarypulmonary embolismembolism
BasedBased on:on: RelevantRelevant SYMPTOMSSYMPTOMS && SIGNSSIGNS AssociatedAssociated RISKRISK FACTORSFACTORS ProbabilityProbability ofof ALTERNATIVEALTERNATIVE DiagnosisDiagnosis OBJECTIVEOBJECTIVE ConfirmationConfirmation
SymptomsSymptoms && SignsSigns ofof PulmonaryPulmonary EmbolismEmbolism inin 21102110 patientspatients 90 82
% 80
o 70 f p f 60 49 Dyspnea
a 50 chest pain ti 40 cough e syncope n 30 20 hemoptysis ts 14 20 7 10 Goldhaber SZ et al. Lancet 353:1386 0 1999 Symptoms PULMONARYPULMONARY EMBOLISMEMBOLISM SIGNSSIGNS TachypneaTachypnea 92%92% CracklesCrackles 58%58% TachycardiaTachycardia 44%44% FeverFever 43%43% IncreasedIncreased ““PP22”” 53%53% PhlebitisPhlebitis 32%32% BloodBlood investigationsinvestigations
ABGsABGs:: HypoxaemiaHypoxaemia andand hypocapniahypocapnia
E.g.E.g. pHpH 7.487.48 PaOPaO22 5252 PaCOPaCO22 2929 DD--dimerdimer byby ELISAELISA AA degradationdegradation productproduct ofof ofof crosslinkedcrosslinked fibrinfibrin HasHas aa highhigh negativenegative predictivepredictive value:value: R/OR/O PEPE inin lowlow clinicalclinical probabilityprobability ECGECG FINDINGSFINDINGS SinusSinus TachycardiaTachycardia 43%43% ““TT”” wavewave inversioninversion 40%40% STST segmentsegment depressiondepression 33%33% LowLow voltagevoltage 16%16% LL axisaxis 12%12% S1S1 Q3Q3 T3T3 11%11% STST elevationelevation 11%11% RR BundleBundle BranchBranch BlockBlock 11%11%
XX--RAYRAY FINDINGSFINDINGS
DiaphragmDiaphragm elevationelevation 41%41%
ConsolidationConsolidation 40%40% PleuralPleural effusioneffusion 28%28% DistendedDistended prox.prox. PulmPulm artart ((FleischnerFleischner’’ss sign)sign) 23%23% AtelectasisAtelectasis/infiltrates/infiltrates 20%20% OligemiaOligemia ((WestermarkWestermark’’ss sign)sign) 15%15%
LungLung infarctinfarct ((HamponHampon’’ss hump)hump)
EchocardiogramEchocardiogram SpiralSpiral CTCT ScanScan EasilyEasily donedone nonnon invasiveinvasive testtest withwith fewfew complicationscomplications RequiresRequires properproper equipmentequipment andand experiencedexperienced readersreaders RarelyRarely cannotcannot performperform e.g.e.g. allergy,allergy, SVCSVC syn.syn. RenalRenal insufficiency,insufficiency, ApproximatelyApproximately 1010-- 13%13% SensitivitySensitivity 90%,90%, specificityspecificity 95%,95%, withwith multidetectormultidetector CTCT inin experiencedexperienced handshands
RightRight ventricularventricular failurefailure
IncreasedIncreased riskrisk ofof suddensudden deathdeath DilatedDilated RVRV andand normalnormal oror smallsmall LVLV RV/LVRV/LV shortshort axesaxes rationration >> 11 RV/LVRV/LV shortshort axisaxis ratioratio >> 1.51.5 indicatesindicates aa severesevere epidsodeepidsode ofof PEPE LeftwardLeftward septalseptal bowingbowing
V/QV/Q scanscan PulmonaryPulmonary angiographyangiography WorkWork upup forfor DVTDVT
Contrast venography Radionuclide venography Doppler USG
Doppler/US TreatmentTreatment
AnticoagulationAnticoagulation unfractionatedunfractionated heparinheparin LowLow molecularmolecular weightweight heparinheparin warfarinwarfarin IVCIVC filterfilter ThrombolyticThrombolytic EmbolectomyEmbolectomy
TREATMENTTREATMENT ofof PULMONARYPULMONARY EMBOLISMEMBOLISM
StartStart oraloral anticoagulantsanticoagulants inin 2424 --7272 hrs.hrs. withwith 55 dayday crossovercrossover withwith heparinheparin Duration:Duration: -- 33 -- 66 monthsmonths ifif correctablecorrectable causecause e.g.e.g. surgerysurgery -- indefinitelyindefinitely ifif nono knownknown causecause oror recurrentrecurrent oror ongoingongoing riskrisk e.ge.g cancercancer ThrombolyticThrombolytic therapytherapy
MoreMore rapidrapid inin effecteffect CanCan bebe consideredconsidered inin patientspatients hemodynamicallyhemodynamically compromisedcompromised oror withwith RVRV dysfunctiondysfunction RR--tPAtPA 10mg10mg bolusbolus thethe 90mg90mg iviivi overover 22 hours,hours, plusplus heparinheparin
IVCIVC filterfilter
Case:Case: F/83,F/83, HSCHSC
DMDM // HT/HT/ IHDIHD SlippedSlipped andand fellfell withwith ## rightright NOF.NOF. OTOT postponedpostponed forfor 22 weeks.weeks. ClexaneClexane 30mg30mg Q12HQ12H SCSC inin orthoortho unit.unit. AlsoAlso onon aspirinaspirin 80mg80mg dailydaily POPO.. ProgressProgress
PostPost--opop hypotensionhypotension withwith dropdrop inin HbHb.. ExtensiveExtensive bruisingbruising overover bothboth arms.arms. Echo:Echo: PoorPoor LV.LV. LVHLVH withwith collapsedcollapsed RV.RV. SmallSmall rimrim ofof pericardialpericardial effusion.effusion. PersistentPersistent oozingoozing fromfrom wound.wound. SignificantSignificant bloodblood--stainedstained outputoutput fromfrom redivacredivac drain.drain. HbHb toppedtopped upup butbut slowlyslowly dropdrop toto 77 againagain.. OutcomeOutcome
OozingOozing graduallygradually stoppedstopped ClearClear upup ofof bloodblood--stainedstained woundwound dischargedischarge afterafter 22 days.days. WeanedWeaned offoff inotropeinotrope andand extubatedextubated.. EventEvent raterate vsvs INRINR PreventionPrevention protocolprotocol Low Medium High
Proximal vein ~ 0.4% ~ 2-4% ~ 10-20% thrombosis
Fatal PE < 0.2% ~ 0.2 – 0.5% ~ 1-5%
Others < 40 years old > 40 years old: Major surgery, trauma, or Major general, urological, illness, with previous DVT / PE / thrombophilia. Major surgery (>30 gynaecological, cardiothoracic, PE / thrombophilia. mins) but with no vascular, or neurosurgical operation. other risk factors. Major pelvic or abdominal < 40 years old: surgery for cancer Minor surgery (>30 Major operation and with one or mins) but with no more other risk factors. Critical leg ischaemia or major other risk factors. Major trauma. leg amputation. Minor surgery, trauma, or illness, and Minor trauma or with one or more other risk factors. Major orthopaedic surgery / illness Plaster cast immobilisation of leg. pelvis, hip, or knee # / SC injury. Major acute medical illness. injury.
Ischaemic stroke. Severely Acute General surgery Elective Elective ill Elective hip spinal Low Moderate High knee neuro- medical replacement cord risk risk risk replacement surgery illness injury Compression elastic stockings Intermittent pneumatic compression Early mobilization, if feasible Unfractionated
heparin (Q8H) 5000iu/dose (Q12H) (Q8H) or SC Enoxaparin
20mg (0.2ml)- 40mg (0.4ml) or or daily SC Tinzaparin 3500iu daily SC
ContraindicationsContraindications
CompressionCompression ElasticElastic StockingStocking // IntermittentIntermittent pneumaticpneumatic compressioncompression (IPC)(IPC) Local leg condition : Dermatitis, post venous ligation operation, gangrene and recent skin graft. Severe atherosclerosis or other ischaemic vascular disease. Massive edema of legs or pulmonary edema due to congestive heart failure. Extreme deformity of leg. Suspected / confirmed DVT. Anticoagulation: bleeding tendency Antithrombotic Agent: Evidence or high risk of active bleeding
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