Pulmonary edema is acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding. Findings are severe dyspnea, diaphoresis, wheezing, and sometimes blood-tinged frothy sputum. Diagnosis is clinical and by chest x-ray. Treatment is with O2, IV nitrates, diuretics, and sometimes morphine and short-term IV positive inotropes, endotracheal intubation, and mechanical ventilation.
If left ventricular (LV) filling pressure increases suddenly, plasma fluid moves rapidly from pulmonary capillaries into interstitial spaces and alveoli, causing pulmonary edema. Although precipitating causes vary by age and country, about one half of cases result from acute coronary ischemia; some from decompensation of significant underlying heart failure (HF), including diastolic dysfunction HF due to hypertension; and the rest from arrhythmia, an acute valvular disorder, or acute volume overload often due to IV fluids. Drug or dietary nonadherence is often involved.
Symptoms and Signs
Patients present with extreme dyspnea, restlessness, and anxiety with a sense of suffocation. Cough producing blood-tinged sputum, pallor, cyanosis, and marked diaphoresis are common; some patients froth at the mouth. Frank hemoptysis is uncommon. The pulse is rapid and low volume, and BP is variable. Marked hypertension indicates significant cardiac reserve; hypotension with systolic BP < 100 mg Hg is ominous. Inspiratory fine crackles are widely dispersed anteriorly and posteriorly over both lung fields. Marked wheezing (cardiac asthma) may occur. Noisy respiratory efforts often make cardiac auscultation difficult; a summation gallop—merger of 3rd (S3) and 4th (S4) heart sounds—may be present. Signs of right ventricular (RV) failure (eg, neck vein distention, peripheral edema) may be present.
A COPD exacerbation can mimic pulmonary edema due to LV failure or even that due to biventricular failure if cor pulmonale (see Cor Pulmonale) is present. Pulmonary edema may be the presenting symptom in patients without a history of cardiac disorders, but COPD patients with such severe symptoms usually have a history of COPD, although they may be too dyspneic to relate it.
A chest x-ray, done immediately, is usually diagnostic, showing marked interstitial edema. Bedside measurement of serum BNP/NT-proBNP levels (elevated in pulmonary edema; normal in COPD exacerbation) is helpful if the diagnosis is in doubt. ECG, pulse oximetry, and blood tests (cardiac markers, electrolytes, BUN, creatinine and, for severely ill patients, ABGs) are done. Echocardiography may be helpful to determine the cause of the pulmonary edema (eg, MI, valvular dysfunction, hypertensive heart disease, dilated cardiomyopathy) and may influence the choice of therapies. Hypoxemia can be severe. CO2 retention is a late, ominous sign of secondary hypoventilation.
Initial treatment includes identifying the cause; 100% O2 by nonrebreather mask; upright position; furosemide 0.5 to 1.0 mg/kg IV or by continuous infusion 5 to 10 mg/h; nitroglycerin 0.4 mg sublingually q 5 min, followed by an IV drip at 10 to 20 mcg/min, titrated upward at 10 mcg/min q 5 min as needed to a maximum 300 mcg/min if systolic BP is > 100 mm Hg. Morphine, 1 to 5 mg IV once or twice, has long been used to reduce severe anxiety and the work of breathing but is decreasingly used, as noninvasive ventilatory assistance with bilevel positive airway pressure (BiPAP) is helpful if hypoxia is significant. If CO2 retention is present or the patient is obtunded, tracheal intubation and assisted ventilation are required (see Tracheal Intubation).
Specific additional treatment depends on etiology:
In patients with acute MI, fluid status before onset of pulmonary edema is usually normal, so diuretics are less useful than in patients with acute decompensation of chronic HF and may precipitate hypotension. If systolic BP falls < 100 mm Hg or shock develops, IV dobutamine and an intra-aortic balloon pump (counterpulsation) may be required.
Some newer drugs, such as IV BNP (nesiritide) and Ca-sensitizing inotropic drugs (levosimendan, pimobendan), vesnarinone, and ibopamine, may have initial beneficial effects but do not appear to improve outcomes compared to standard therapy, and mortality may be increased.
Once patients are stabilized, long-term HF treatment is begun (see see Treatment).
Last full review/revision September 2013 by J. Malcolm O. Arnold, MD
Content last modified October 2013