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Overview |
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Definition |
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Pulmonary edema is characterized by the abnormal accumulation of pulmonary
interstitial or alveolar fluid. Pulmonary edema due to heart disease increases
in adults over age 40; the incidence rate due to noncardiogenic causes is
approximately 150,000 cases each year. The two primary subtypes
are:
- Cardiogenic pulmonary edema—associated with
congestive heart failure or other heart disease
- Noncardiogenic pulmonary edema—associated
with a number of clinical conditions (e.g., acute severe asthma, lymphatic
blockade, lymphangitis carcinomatosis, iatrogenic fluid overload, drug
intoxication)
Other forms of pulmonary edema in which the exact mechanisms have not been
fully explained include:
- Narcotic-overdose pulmonary edema
- High-altitude pulmonary edema
- Neurogenic pulmonary edema
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Etiology |
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Causes are cardiogenic or noncardiogenic. The biological factors in the
etiology of pulmonary edema include altered capillary permeability (e.g., from
infections or inhaled toxins), increased pulmonary venous pressure (e.g., from
left ventricle failure, mitral stenosis, or pulmonary venous disease), and
decreased plasma oncotic pressure (e.g., hypoalbuminemia).
A variety of noncardiogenic factors can also cause pulmonary edema, including
shock, drug overdose (e.g., from heroin), high altitude, transfusion reactions,
CNS trauma, the Hanta virus, multiple trauma, eclampsia, and oxygen
toxicity. |
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Risk Factors |
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- Hypertension
- Diabetes
- Coronary or valvular heart disease
- Obesity
- Smoking
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Signs and Symptoms |
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- Dyspnea
- Tightness in chest
- Angina
- Rales
- Rhonchi
- Cyanosis
- Diaphoresis
- Pink, frothy sputum
- Anxiety
- Lower extremity
edema
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Differential
Diagnosis |
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Differentiate cardiogenic from noncardiogenic causes:
- Pneumonia
- Asthma
- COPD exacerbation
- Hyperventilation syndrome
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Diagnosis |
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Physical Examination |
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Signs of pulmonary edema include tachypnea, tachycardia, and elevated blood
pressure. A fever may indicate concurrent infection. Other physical
presentations include cyanosis, diaphoresis, retractions, wheezing, rales, cough
with pink and frothy sputum, S3 gallop or murmur (may indicate
valvular disease), peripheral edema, and bruits. The Swan-Ganz catheter may be
used to obtain pulmonary vascular pressure and differentiate between cardiogenic
and noncardiogenic forms. |
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Laboratory Tests |
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A variety of laboratory tests can help in detecting underlying etiology but
are not considered specific for pulmonary edema.
- Blood tests, including CBC with differential, electrolyte, BUN,
creatinine, and serum protein concentrations
- Urinalysis and microscopic examination of urine to detect
proteinuria
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Pathology/Pathophysiology |
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- Imbalance of Starling forces
- Decreased plasma oncotic pressure
- Increased negativity of interstitial pressure
- Altered alveolar-capillary membrane permeability
- Lymphatic insufficiency
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Imaging |
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- Echocardiogram to determine underlying cause, such as valvular
disease or cardiomyopathy
- Chest X ray to reveal interstitial edema and pulmonary vasculature
shadows. (Clinical presentations may not appear on chest X rays for up to 12
hours; may also take up to four days to clear after clinical improvement.)
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Other Diagnostic
Procedures |
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Acute pulmonary edema is a life-threatening medical emergency. As a result,
treatment may have to begin before making a complete diagnosis. The primary goal
after initial treatment is to distinguish between cardiogenic and noncardiogenic
forms. Diagnostic measures include taking a detailed medical history, including
past history of cardiac and pulmonary disease, hypertension, shortness of
breath, orthopnea, dyspnea on exertion, faintness, chest pain, recent weight
gain, general edema, recent infection, and exposure to toxic inhalants or smoke.
Diagnosis of pulmonary edema resulting from chronic forms of heart failure
should focus on identifying underlying cardiac disorder (e.g., arrhythmia or
infection). Tests include:
- Arterial blood gas
- ECG
- Pulmonary function
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Treatment Options |
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Treatment Strategy |
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Depending on the cause of pulmonary edema, several general measures are
recommended for immediate stabilization and long-term prevention against
recurrent episodes.
- Administration of 100% oxygen (to achieve arterial PO2 greater than
60 mm Hg) via nasal cannula or mask. Maintain patient in sitting position with
legs dangling (facilitates respiration and reduces venous return) or elevate
head of bed 30 degrees.
- Mechanical ventilation
- Rotating tourniquet applied to extremities
- Pharmacotherapy
- Surgery (indicated in rare cases, including valvular heart disease or
ventricular septum rupture after myocardial infarction)
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Drug Therapies |
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- Morphine (2 to 5 mg) as needed to reduce congestion and anxiety
- Diuretics, such as furosemide (40 to 80 mg) or ethacrynic acid (40 to
100 mg), given intravenously to reduce circulating blood volume
- Vasodilators, such as IV nitroglycerin (10 to 20 mcg/min increased by
10 to 20 mcg/min every five minutes until effective) or sodium nitroprusside
administered intravenously (10 mcg/min titrated to goal of systolic blood
pressure of 100 to 110 mm Hg) to decrease afterload and left ventricular work
- Digoxin can be administered orally (usual loading dose is 1 mg in 3
to 4 doses/24 hours, intravenously or orally) to achieve serum levels of 1.00 to
1.5 ng/ml; prior to administration, check for previous digoxin use and adverse
reactions; also check for history of renal, pulmonary, liver, or thyroid
disease; some medications used by patient might affect digoxin.
- Dobutamine (2.5 to 15 mcg/kg/min) or dopamine (2 to 20 mcg/kg/min)
for inotropic support
- Aminophylline (theophylline ethylenediamine) (240 to 480 mg
intravenously) to diminish bronchoconstriction, increase renal blood flow and
sodium excretion, and augment myocardial
contractility
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Complementary and Alternative
Therapies |
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Pulmonary edema is most often a sign of advanced pathology. Alternative
therapies may be helpful in strengthening the cardiopulmonary system and
reducing the severity of the disease. |
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Nutrition |
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- Increase dietary potassium and magnesium with diuretic use (e.g.,
bananas, apricots, nuts, seeds, dandelion leaves [Taraxacum
officinale], and green leafy vegetables).
- Coenzyme Q10 (100 mg bid) supports cardiac function, is an
antioxidant, and oxygenates tissues.
- L-carnitine (500 mg tid) improves endurance and is needed for
efficient cardiac function.
- Magnesium aspartate (200 mg bid to tid) increases efficiency of
cardiac muscle and decreases vascular resistance. In addition, magnesium and
calcium (1,000 mg/day) influence intra- and intercellular fluid exchange and may
be depleted with diuretic use.
- Potassium aspartate (20 mg/day) improves heart contractility and
should be supplemented with diuretic use.
- Vitamin E (400 IU/day) is an antioxidant and is
cardioprotective.
- Vitamin C (1,000 to 1,500 mg tid) is an antioxidant, improves
vascular integrity, and stimulates immune function.
- Taurine (500 mg bid) enhances the efficiency of cardiac function and
may increase diuresis.
- Raw heart concentrate (100 to 200 mg/day) provides essential
nutrients to the heart.
- Selenium (200 mcg/day) is an antioxidant that protects both heart and
lung tissues.
- Choline (250 to 500 mg/day) and inositol (150 to 200 mg/day) are part
of the phospholipid membrane and positively effect parasympathetic activity and
vasodilation.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
The goals of herbal therapy are to enhance the function of the
cardiopulmonary systems, improve vascular tone, and increase diuresis. A general
diuretic should contain herbs that support circulation and lymphatic drainage.
They are best administered in a tea (4 to 6 cups/day), although a tincture may
be used (30 to 60 drops qid). Combine three of these herbs with equal parts of
two to three additional herbs from the following categories, according to the
underlying cause. Cleavers (Galium aparine), yarrow (Achillea
millefolium), oatstraw (Avena sativa), elder (Sambucus nigra),
red clover (Trifolium pratense), fresh parsley (Petroselinum
crispus), and dandelion leaf (Taraxacum officinale).
Noncardiogenic pulmonary edema:
- Garlic (Allium sativum) enhances expectoration, is
hypotensive, and immune-stimulating. (Garlic can also be taken as capsules,
1,000 to 4,000 mg/day.)
- Rosemary (Rosmarinus officinalis) strengthens cardiac
function, is antispasmodic, and improves circulation to the lungs.
- Linden flowers (Tilia cordata) is an antispasmodic,
hypotensive, anti-atherosclerotic, respiratory relaxant, and expectorant. Also
stimulates immune function.
- Indian tobacco (Lobelia inflata) stimulates respiratory
function, is antispasmodic, and hypotensive. At high doses this herb has toxic
side effects. Used as part of a formula (¼ or less) minimizes risk of toxicity.
You may substitute mullein (Verbascum densiflorum), which also stimulates
respiratory function.
- Thyme leaf (Thymus vulgaris) enhances expectoration, tones
respiratory system, and increases circulation.
For cardiogenic pulmonary edema:
- Hawthorn (Crataegus monogyna) increases cardiac output without
increasing cardiac load. Strengthens the integrity of vasculature and has mild
vasodilation properties.
- Motherwort (Leonurus cardiaca) has antispasmodic properties,
relieves heart palpitations, and enhances cardiac function.
- Rosemary strengthens vasculature and is an antispasmodic heart
tonic.
The following herbs may be very effective in pulmonary edema with cardiac
involvement. Because of their potential side effects they should only be used
under physician supervision. All three increase cardiac output without
increasing cardiac load, have diuretic properties, and have regulating effects
on heart rhythm.
- Lily of the valley (Convalleria majalis)
- Night-blooming cereus (Selenicereus grandiflorus)
- Broom (Sarothamnus scoparius)
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency.
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Physical Medicine |
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Contrast hydrotherapy. Alternating hot and cold applications brings nutrients
to the site and diffuses metabolic waste from inflammation. The overall effect
is decreased inflammation, pain relief, and enhanced healing. Using this
technique with hand and/or foot baths may help to improve circulation and
lymphatic drainage. If possible, immerse the chest (as with an extremity).
Alternate 3 minutes hot with 1 minute cold. Repeat three times to complete one
set. Do two to three sets/day.
Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory.
Apply oil directly to chest, cover with a clean soft cloth (e.g., flannel) and
plastic wrap. Place a heat source (hot water bottle or heating pad) over the
pack and let sit for 30 to 60 minutes. For best results use three consecutive
days. Add four to six drops of essential oils, such as eucalyptus, lavender,
rosemary, and thyme, to increase benefit.
Postural drainage may be helpful in relieving pulmonary congestion.
Tapotement can help prevent consolidation. |
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Acupuncture |
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Acupuncture may improve cardiopulmonary function and provide support in the
treatment of underlying cause. |
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Massage |
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Therapeutic massage can assist with increasing circulation and lymphatic
drainage. |
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Patient Monitoring |
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Once immediate treatment for the acute stage of pulmonary edema is completed,
a careful search for underlying cause should be initiated. Strategic measures
are needed for long-range stabilization, which may include surgery.
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Other
Considerations |
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Prevention |
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Prompt treatment of cardiac disorders can reduce risk. Dietary approaches,
such as a low-salt diet and maintaining an ideal weight, and smoking cessation
are recommended to prevent heart disease. |
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Complications/Sequelae |
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Pulmonary edema can be fatal. It is sometimes misdiagnosed as asthma.
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Prognosis |
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Highly dependent on etiology. Mortality is 50% to 60% for noncardiogenic
pulmonary edema and higher for cardiogenic shock. Following acute phase,
pulmonary edema is often manageable through medications and treatment of
underlying disease. |
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Pregnancy |
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Conventional treatments are indicated as this may be
life-threatening. |
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References |
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Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:73, 80, 155, 156.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:423, 425.
Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md:
Williams & Wilkins; 1998.
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.
Tierney LM Jr, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis
& Treatment 1999. 38th ed. Stamford, Conn: Appleton & Lange;
1999. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |