Conditions with Similar Symptoms
View Conditions
  Drug Monographs
Aminophylline
Digoxin
Diuretics
Dobutamine
Dopamine
Morphine Sulfate
Vasodilators
  Herb Monographs
Dandelion
Garlic
Hawthorn
Linden
Lobelia
Rosemary
Yarrow
  Supplement Monographs
Calcium
Carnitine (L-Carnitine)
Coenzyme Q10
Magnesium
Potassium
Selenium
Vitamin C (Ascorbic Acid)
Vitamin E
  Learn More About
Acupuncture
Homeopathy
Massage Therapy
Nutrition
Western Herbalism
Look Up > Conditions > Pulmonary Edema
Pulmonary Edema
Overview
Definition
Etiology
Risk Factors
Signs and Symptoms
Differential Diagnosis
Diagnosis
Physical Examination
Laboratory Tests
Pathology/Pathophysiology
Imaging
Other Diagnostic Procedures
Treatment Options
Treatment Strategy
Drug Therapies
Complementary and Alternative Therapies
Patient Monitoring
Other Considerations
Prevention
Complications/Sequelae
Prognosis
Pregnancy
References

Overview
Definition

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

Etiology

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.


Risk Factors
  • Hypertension
  • Diabetes
  • Coronary or valvular heart disease
  • Obesity
  • Smoking

Signs and Symptoms
  • Dyspnea
  • Tightness in chest
  • Angina
  • Rales
  • Rhonchi
  • Cyanosis
  • Diaphoresis
  • Pink, frothy sputum
  • Anxiety
  • Lower extremity edema

Differential Diagnosis

Differentiate cardiogenic from noncardiogenic causes:

  • Pneumonia
  • Asthma
  • COPD exacerbation
  • Hyperventilation syndrome

Diagnosis
Physical Examination

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.


Laboratory Tests

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

Pathology/Pathophysiology
  • Imbalance of Starling forces
  • Decreased plasma oncotic pressure
  • Increased negativity of interstitial pressure
  • Altered alveolar-capillary membrane permeability
  • Lymphatic insufficiency

Imaging
  • 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.)

Other Diagnostic Procedures

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

Treatment Options
Treatment Strategy

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)

Drug Therapies
  • 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

Complementary and Alternative Therapies

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.


Nutrition
  • 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.

Herbs

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)

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.


Physical Medicine

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.


Acupuncture

Acupuncture may improve cardiopulmonary function and provide support in the treatment of underlying cause.


Massage

Therapeutic massage can assist with increasing circulation and lymphatic drainage.


Patient Monitoring

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.


Other Considerations
Prevention

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.


Complications/Sequelae

Pulmonary edema can be fatal. It is sometimes misdiagnosed as asthma.


Prognosis

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.


Pregnancy

Conventional treatments are indicated as this may be life-threatening.


References

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.


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.