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Pulmonary Edema

By

Nowell M. Fine

, MD, SM, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary

Last full review/revision Nov 2020| Content last modified Nov 2020
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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 oxygen, IV nitrates, diuretics, and sometimes morphine and, in patients with heart failure and reduced ejection fraction short-term IV positive inotropes , and assisted ventilation (ie, endotracheal intubation with mechanical ventilation or bilevel positive airway pressure 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 Overview of Coronary Artery Disease Coronary artery disease (CAD) involves impairment of blood flow through the coronary arteries, most commonly by atheromas. Clinical presentations include silent ischemia, angina pectoris, acute... read more Overview of Coronary Artery Disease ; some from decompensation of significant underlying heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more Heart Failure (HF) (HF), including HF with preserved ejection fraction Heart failure with preserved ejection fraction (HFpEF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more Heart failure with preserved ejection fraction (HFpEF) (HFpEF) due to hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more Hypertension ; and the rest from arrhythmia Overview of Arrhythmias The normal heart beats in a regular, coordinated way because electrical impulses generated and spread by myocytes with unique electrical properties trigger a sequence of organized myocardial... read more Overview of Arrhythmias , an acute valvular disorder Overview of Cardiac Valvular Disorders Any heart valve can become stenotic or insufficient (also termed regurgitant or incompetent), causing hemodynamic changes long before symptoms. Most often, valvular stenosis or insufficiency... read more , or acute volume overload often due to IV fluids. Drug or dietary nonadherence is often involved.

Symptoms and Signs of Pulmonary Edema

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 blood pressure (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.

Diagnosis of Pulmonary Edema

  • Clinical evaluation showing severe dyspnea and pulmonary crackles

  • Chest x-ray

  • Sometimes serum brain natriuretic peptide (BNP) or N-terminal-pro BNP (NT-pro-BNP)

  • ECG, cardiac markers, and other tests for etiology as needed

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 [blood urea nitrogen], creatinine and, for severely ill patients, arterial blood gas [ABG] measurements) are done.

Hypoxemia can be severe. Carbon dioxide retention is a late, ominous sign of secondary hypoventilation.

Treatment of Pulmonary Edema

  • Treatment of cause

  • Oxygen

  • IV diuretic

  • Nitrates

  • IV inotropes

  • Morphine

  • Ventilatory assistance

Initial treatment includes identifying the cause; 100% oxygen by nonrebreather mask; upright position; furosemide 0.5 to 1.0 mg/kg IV or by continuous infusion 5 to 10 mg/hour; nitroglycerin 0.4 mg sublingually every 5 minutes, followed by an IV drip at 10 to 20 mcg/minute, titrated upward at 10 mcg/minute every 5 minutes as needed to a maximum 300 mcg/minute 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 (except in palliative care) due to observational studies suggesting a poorer outcome with its use. Noninvasive ventilatory assistance with bilevel positive airway pressure (BiPAP) is helpful if hypoxia is significant. If carbon dioxide retention is present or the patient is obtunded, tracheal intubation Tracheal Intubation Most patients requiring an artificial airway can be managed with tracheal intubation, which can be Orotracheal (tube inserted through the mouth) Nasotracheal (tube inserted through the nose)... read more and mechanical ventilation Overview of Mechanical Ventilation Mechanical ventilation can be Noninvasive, involving various types of face masks Invasive, involving endotracheal intubation Selection and use of appropriate techniques require an understanding... read more are required.

Specific additional treatment depends on etiology:

  • For acute myocardial infarction or another acute coronary syndrome, thrombolysis or direct percutaneous coronary angioplasty with or without stent placement

  • For severe hypertension, an IV vasodilator

  • For supraventricular or ventricular tachycardia, direct-current cardioversion

  • For rapid atrial fibrillation, cardioversion is preferred. To slow the ventricular rate, an IV beta-blocker, IV digoxin, or cautious use of an IV calcium channel blocker

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 heart failure 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 calcium-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. Serelaxin, a recombinant form of the human pregnancy hormone relaxin-2, has been tried but benefits were not shown in a large international randomized study. Omecamtiv mecarbil, an oral cardiac myosin activator, is being evaluated for ability to reduce morbidity and mortality in patients currently or recently hospitalized with decompensated heart failure.

Key Points

  • Acute pulmonary edema can result from acute coronary ischemia, decompensation of underlying heart failure, arrhythmia, an acute valvular disorder, or acute volume overload.

  • Patients have severe dyspnea, diaphoresis, wheezing, and sometimes blood-tinged frothy sputum.

  • Clinical examination and chest x-ray are usually sufficient for diagnosis; ECG, cardiac markers, and sometimes echocardiography are done to identify cause.

  • Treat the cause and give oxygen and IV furosemide and/or nitrates as needed; try noninvasive ventilatory assistance initially but use tracheal intubation and assisted ventilation if necessary.

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