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Pulmonary edema

Definition

Pulmonary edema is an abnormal build up of fluid in the air sacs of the lungs, which leads to shortness of breath

Causes

Various cardiac diseases cause congestive heart failure (CHF) and pulmonary edema
The most common cause of heart failure is coronary artery disease, which is secondary to loss of left ventricular muscle, ongoing ischemia, or decreased diastolic ventricular compliance
Other disease processes include hypertension, valvular heart disease, congenital heart disease, other cardiomyopathies, myocarditis, and infectious endocarditis
CHF is often precipitated by cardiac ischemia or dysrhythmias, cardiac or extracardiac infection, pulmonary embolus, physical or environmental stresses, changes or noncompliance with medical therapy, dietary indiscretion, or iatrogenic volume overload
One also must consider systemic processes such as pregnancy and hyperthyroidism as precipitants of CHF

Symptoms

Anxiety
Cough
Difficulty breathing
Excessive sweating
Feeling of "air hunger" or "drowning" if this occurs suddenly, awakening you from sleep and causing you to sit up and catch your breath, it's called "paroxysmal noctural dyspnea"
Grunting or gurgling sounds with breathing
Pale skin
Restlessness
Shortness of breath , shortness of breath when lying down (orthopnea) -- you may need to sleep with your head propped up or use extra pillows
Wheezing
Coughing up blood or bloody froth
Decrease in level of alertness (consciousness)
Inability to speak in full sentences
Nasal flaring

Signs and tests

The health care provider will perform a physical exam and use a stethoscope to listen to the lungs and heart. The following may be detected:
Crackles in the lungs, called rales
Abnormal heart sounds
Increased heart rate (tachycardia)
Pale or blue skin color (pallor or cyanosis)
Rapid breathing (tachypnea)
Possible tests include:
Complete blood count (CBC) to check for anemia and reduced red cell count
Other blood tests to measure blood chemistries and kidney function
Blood oxygen levels (oximetry or arterial blood gases) -- low in patients with pulmonary edema
Chest x-ray may reveal fluid in or around the lung space or an enlarged heart
Electrocardiogram (ECG) to detect abnormal heart rhythm or evidence of a heart attack
Ultrasound of the heart (echocardiogram) to see if there is a weak heart muscle, leaky or narrow heart valves, or fluid surrounding the heart

Medical management

Prehospital Care

Prehospital notification by emergency medical services (EMS) personnel should alert ED staff of a patient presenting with signs and symptoms of congestive heart failure (CHF) and pulmonary edema
They should receive online medical advice for patients with high-risk presentations
Begin treatment with the ABCs
Administer supplemental oxygen, initially 100% nonrebreather facemask
Use cardiac monitoring and continuous pulse oximetry
Obtain intravenous access, as well as a prehospital ECG, if available
Provide nitroglycerin sublingual or spray for active chest pain in the patient without severe hypotension and intravenous Furosemide "diuretic"

Emergency Department Care

Begin ED treatment of a patient presenting with signs and symptoms of congestive heart failure (CHF) and pulmonary edema with the ABCs
Administer supplemental oxygen, initially 100% nonrebreather facemask
Use cardiac monitoring and continuous pulse oximetry
Obtain intravenous access
To reduce venous return, elevate the head of the bed. Patients may be most comfortable in a sitting position with their legs dangling over the side of the bed, which allows for reduced venous return and decreased preload
Therapy generally starts with nitrates and diuretics if patients are hemodynamically stable
Many other treatment modalities may play some role in acute management
If possible, treat the underlying cause as well, if identified
This is particularly necessary for patients with known diastolic dysfunction who respond best to reductions in blood pressure, rather than to diuretics, nitrates, and inotropic agents. Serum BNP levels may be very useful in the setting of undifferentiated dyspnea, or in the future may be useful to gauge therapeutic success
Eliminate contributing factors when possible
Restrict fluid and sodium
Consider other treatment modalities, including nesiritide
Nesiritide may be useful in lieu of nitroglycerin in patients with moderate respiratory distress, particularly if the patient will not tolerate noninvasive ventilation or in the patient who cannot have nitroglycerin by protocol
Data comparing nasal CPAP therapy and facemask ventilation therapy have demonstrated decreased need for intubation rates when these modalities are used
However, in patients with severe CHF treated with CPAP, no significant difference was found in short-term mortality rates and length of hospital stay
Although BiPAP therapy may improve ventilation and vital signs more rapidly than CPAP, a higher incidence of MI associated with BiPAP has been reported
BiPAP and CPAP are contraindicated in the presence of acute facial trauma, the absence of an intact airway, and in patients with an altered mental status or who are uncooperative
Alternating tourniquets, formerly a mainstay of therapy, have been used to decrease preload
Their use has been supplanted by newer therapies such as intravenous nitroglycerin and nitroprusside
Phlebotomy with removal of 500 mL of blood or via plasmapheresis is another former mainstay of therapy used to decrease preload
Its use has been supplanted by newer therapies such as intravenous nitroglycerin and nitroprusside

Nursing Intervention

Monitor for signs of respiratory distress
Provide pulmonary hygiene as needed
Administer oxygen as prescribed
Keep the head of the bed elevated
Monitor ABG values.
Monitor for signs of altered cardiac output, including Pulmonary edema Arrhythmias, including extreme tachycardia and bradycardia
Characteristic ECG and heart sound changes report the physician
Evaluate fluid status
Maintain strict fluid intake and output measurements
Monitor daily weights
Assess for edema and severe diaphoresis
Monitor electrolyte values and hematocrit level
Maintain strict fluid restrictions as prescribed
Place in an upright sitting position, with feet and legs down to prevent further lung engorgement and to favor pooling of blood in dependent area of body
Auscultate lungs sound every 30 minutes
Prepare for intubation
Check blood pressure every 15-30 minutes
Assess & record quality of pulse
Assess mental status for signs and symptoms of cerebral hypoxia Administer IV morphine sulfate as ordered
Administer diuretics as ordered
Administer aminophylline IV as ordered
Expectations (prognosis)
Some patients may need to use a breathing machine for a long time, which may lead to damage to lung tissue.
Kidney failure and damage to other major organs may occur if blood and oxygen flow are not restored promptly. If not treated, this condition can be fatal

Complications

Complications of congestive heart failure (CHF) and pulmonary edema may include the following:
Acute MI
Cardiogenic shock
Arrhythmias (most commonly atrial fibrillation)
Ventricular arrhythmias, such as ventricular tachycardia, often are seen in patients with significantly depressed left ventricular function.
Electrolyte disturbances
Mesenteric insufficiency
Protein enteropathy
Digitalis intoxication

Prevention

Emphasize patient education with intense instruction regarding compliance with dietary restrictions and medical therapy.
Emphasize close monitoring of blood pressure, particularly in patients with diastolic dysfunction.
Patient should modify diet as follows:
Sodium restriction (initially 4 g/d)
Weight reduction (if appropriate)
Appropriate fluid restriction
Patient should modify activity as follows:
During severe stage, bed rest with elevation of head of bed and anti-embolism stockings to help control leg edema
Gradual increase in activity with walking to help increase strength