4/10/2019 Cardiogenic and Non-Cardiogenic Pulmonary Edema--Pathomechanisms and Causes* - WSAVA2010 - VIN

Cardiogenic and Non-Cardiogenic Pulmonary Edema--Pathomechanisms and

Causes*

W S A V A W C P , 2010
Johann Lang, Prof.Dr.med.vet., DECVDI; Tony M. Glaus, PD, Dr.med.vet., DACVIM, DECVIM-CA
Berne and Zurich, Switzerland

Read the German translation: Kardiales und Nicht-Kardiales Lungenödem--

Pathomechanismen und Ursachen*
Introduction
The physiological fluid movement through a vascular membrane into the
surrounding tissue depends on 3 factors: membrane permeability, oncotic pressure
gradient and hydrostatic pressure gradient. As an additional factor, lymphatic
drainage counteracts extravascular fluid accumulation. Edema develops, if one of
these 4 factors is disturbed in a degree that cannot be compensated. For
pulmonary edema to develop, essentially always an increased intravascular
hydrostatic pressure or a disturbed vascular permeability is responsible. For clinical
purposes, pulmonary edema is grossly divided based on pathophysiology in
cardiogenic and non-cardiogenic edema. The exact differentiation and diagnosis is
made based on a combination of clinical and radiological findings and
considerations.
Pathogenesis and Causes of Cardiogenic Pulmonary Edema
Cardiogenic pulmonary edema develops secondary to a rise of hydrostatic pressure
in the pulmonary capillaries (normal <12 mmHg). When the rise in pressure is
gradual, pressure may exceed 20 mmHg before pulmonary edema develops,
because the capacity of lymphatic drainage can be increased.1 For cardiogenic
pulmonary edema to develop, by definition there must be left-sided congestive heart
failure for which there must be an identifiable underlying cardiac disease. Most
important diseases are acquired, advanced degenerative mitral valve disease and
dilated cardiomyopathy, and congenital, patent ductus arteriosus.
Radiologically, congestion is manifested by dilated pulmonary veins and
cardiogenic edema that in dogs initially is characterized by an increased interstitial
lung pattern progressing to an alveolar pattern. Typically, the edema starts in the
perihilar area progressing to the caudo-dorsal lung parts. In addition, there should
generally be clear radiological signs of left sided cardiac disease with distinct left
atrial dilation, as well as clear clinical signs of an underlying cardiac disease that
concurs with the radiograph findings.2
Pathogenesis and Causes of Non-Cardiogenic Pulmonary Edema
Various mechanisms are responsible for non-cardiogenic edema to develop, i.e., low
alveolar pressure, increased vascular permeability, increased hydrostatic pressure
and a combination of these. The various causes, according to pathophysiology are:
low alveolar pressure--postobstructive edema; low alveolar pressure--reexpansion
edema; neurogenic edema; vasculitis; high altitude pulmonary edema.
Decreased alveolar pressure develops after fast removal of pleural effusion,
pneumothorax, or lung lobes, called reexpansion edema. Mortality from this rare
complication in people is described as 20%.3 In veterinary medicine, 2 feline cases
45
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4/10/2019 Cardiogenic and Non-Cardiogenic Pulmonary Edema--Pathomechanisms and Causes* - WSAVA2010 - VIN
have been described that both died.4,5
Decreased alveolar pressure also results from upper airway obstruction, called
postobstructive edema; e.g., in brachycephalic syndrome, laryngeal paralysis,
tracheal collapse, strangulation, and iatrogenic during intubation and bronchoscopy.6-
8
The non-cardiogenic edema in some hunting dogs may partially be caused by
obstruction, specifically laryngeal edema associated with prolonged and constant
barking. More likely in these dogs is a neurogenic edema associated with a very high
catecholamine level (see below).9 Postobstructive pulmonary edema in dogs and
cats is probably much more common than diagnosed. Many cases are probably
diagnosed as cardiogenic edema, because dyspnea and edema are associated with
exercise or a stress situation, e.g., in laryngeal paralysis or edema associated with
anesthesia, or because affected animals may have two concomitant diseases, e.g.,
tracheal collapse and degenerative mitral valve disease.
A further important cause of non-cardiogenic edema is neurogenic edema.
Pathophysiologically, excessive sympatho-adrenergic activation in the medulla
oblongata plays the central role. This results in pulmonary venous constriction
shifting blood from the systemic to the pulmonic circulation, increase in pulmonary
hydrostatic pressure and finally edema.10 Causes described in dogs are brain
trauma, epileptic seizures, and electrocution.6,11,12 The pulmonary edema in hunting
dogs during or after the hunt is also thought to be caused by excessive
catecholamine secretion, and thus to be a neurogenic edema.9 A particular
pathogenesis of neurogenic pulmonary edema is the one in endurance athletes
caused by cerebral edema elicited by hyponatremia.13 Prognosis for complete
recovery in neurogenic edema is good with adequate supportive care.
Of big importance for the development of non-cardiogenic edema is the acute
(formerly adult) respiratory distress syndrome, ARDS.14 The underlying cause is
severe and diffuse damage of the lung parenchyma resulting in endothelial and
epithelial disturbance of permeability and exit of protein rich fluid. Complicating
factors are coagulation disturbances, perfusion disturbances and loss of surfactant.
ARDS may be a complication of primary lung damage, e.g., after inhalation of toxic
gas (smoke intoxication), aspiration of gastric content, inhalation of hyperbaric
oxygen (oxygen intoxication) or pneumonia. ARDS may also be a complication of a
severe systemic disease, like sepsis, extensive burn and acute pancreatitis. The
prognosis even with intensive supportive care is poor.15 Pulmonary edema similar to
ARDS can be elicited by multiple blood transfusions; even though this complication is
life threatening, the prognosis is much better than in ARDS.14,16
A further important cause of protein-rich pulmonary edema is vasculitis and
disturbed vascular permeability, in dogs well recognized in leptospirosis.17 This may
be complicated by prognostically important pulmonary hemorrhages, that may not be
differentiated radiologically from edema.18
Finally, high altitude above around 3000 m may cause non-cardiogenic pulmonary
edema in susceptible individuals.
No Pulmonary Edema in Low Oncotic Pressure
Even though oncotic pressure, primarily depending on plasma albumin
concentration, is one of the important factors to keep fluid inside the vasculature, it
does not play an important role in the lungs. The pulmonary interstitial space
normally has a higher albumin concentration than other interstitial tissue and a small
oncotic gradient, because the permeability of pulmonary capillaries is higher than in
other capillaries. When plasma albumin drops, the interstitial albumin concentration
drops as well, therefore not markedly affecting the oncotic gradient. Thus, it is
unusual to find pulmonary edema when hypoalbuminemia is the only abnormality.19
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Therapeutic Principles for Pulmonary Edema
In cardiogenic pulmonary edema, the central therapeutic focus is to decrease
preload by aggressive diuresis using loop diuretics. In contrast, the various
mechanisms of non-cardiogenic edema are not affected by diuresis. Even more, in
various diseases fluid therapy rather than diuresis to supportively treat the
underlying disease is indicated, e.g., in sepsis, pancreatitis and leptospirosis.
However, in these cases, infusion therapy has to be defensive / cautious. The
primary supportive measure is optimized oxygenation. Depending on edema cause
and severity, keeping an animal quiet in an oxygen-rich environment may suffice, or
artificial respiration using positive end-expiratory pressure (PEEP) may be needed.20
The usefulness of glucocorticoids is controversial. In a recent human study, low
dose and early application of methylprednisolone had a positive effect on the course
in ARDS.21 Furthermore, extrapolated from human medicine, steroids seem useful
in the pulmonary edema in leptospirosis.22
In summary, cardiogenic and non-cardiogenic causes are responsible for
pulmonary edema to develop. The exact identification of the underlying cause is of
paramount importance for therapy and prognosis. With progressive specialization
also in intensive care medicine and with similar large dedication of veterinarians and
animal owners for time-consuming and costly treatments, more and more so-called
hopeless cases may be completely cured.
*Published in Schweiz. Arch. Tierheilk. 2010 (in German)
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S I
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Johann Lang, Prof., Dr. med. vet., DECVDI (/apputil/content/defaultadv1.aspx?

pId=11310&authorId=40164)
Bern, Schweiz

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