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